E/M level 99214

cnramsey

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When I work this up I am getting a 99214. Provider picked a 99213 and wants it to stay at a 99213. Providers reasoning patient is healthy. Our coding department is taking the CEMC course and everything I read and see in the pretest scenarios supports a 99214. Please review the document below and explain to me why this is or isn't a 99214. I'm getting HPI 99213 Exam 99214 MDM 1 new problem to provider 99214 with Risk Management Moderate for the Amox Rx 99214 which leaves me with a 99214 for the Exam and MDM.

Primary Care Provider:
Accompanied by: Mother
Visit Type: Acute Visit

Chief Complaint: sore throat swollen glands

History of Present Illness:
Patient presents today for sore throat, fevers 3-4 days ago. Reports that its pretty severe and has been having trouble eating because of the pain. Has only been treating it with cough drops. Mom noticed that was really hot this AM, although she did not take temp.

Problem List Changes:
Added new problem of Strep pharyngitis (strep throat) (ICD-034.0) (ICD10-J02.0)
Assessed Strep pharyngitis (strep throat) as new

Review of Systems:
General: COMPLAINS OF FEVER.
HEENT: COMPLAINS OF SORE THROAT, SINUS CONGESTION, RHINORRHEA, EAR PAIN.
Respiratory: COMPLAINS OF COUGH.

Vital Signs:
Weight: 1XX lbs. (79.09 Kg.) Height: 65.50 in. (166.37 cm.) BMI: 28.62
Temperature: 98.8 deg F. (37.1 deg C.) Temperature Site: Tympanic
Respiration: 16 O2 Sat: 98 On: Room air Pulse: 83 Pulse Rhythm: Regular
Blood Pressure #1: 110/74 mm Hg. Location: Lt Arm Position: sitting
Entered by:

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI; conjunctiva and sclera clear.
Ears: TM's intact and clear with normal canals and pinnae.
Nose: No deformity/significant septal deviation; Normal mucosa.
Mouth: Tonsillar enlargement/erythema with exudate
Erythematous posterior pharynx
Neck: Mildly tender cervical adenopathy present
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Throat:
Rapid Strep: positive

Assessment and Plan:
• STREP PHARYNGITIS (STREP THROAT) (ICD-034.0) (ICD10-J02.0) New
Start with amoxicillin today.
Ibuprofen, warm drinks and follow up as needed.


Orders:
Est. Level 3: Limited [CPT-99213]

Laboratory Results
Date/Time Received: 12/20/19
Rapid Strep: positive
 

katemae84

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I think your provider is correct in choosing a 99213 for this. Yes, this visit can meet a 99214 on an auditing tool, but remember that there are other considerations when determining a level of E/M service. In addition to the three "key components" (History, Exam and MDM), the CPT book also lists "contributory factors" in the E/M Services Guidelines that should also be considered when selecting an E/M level, such as counseling, coordination of care and nature of the presenting problem. No matter how many boxes you can check off on an audit tool, medical necessity is the over-arching criterion for payment, and insurance companies will not like to see a consistent habit of charging 99214's visits for acute illnesses in otherwise healthy patients that have a low risk of mortality or functional impairment without treatment, like strep, conjunctivitis and sinusitis.

Basically, there is a difference between the correct answer for a test like the CEMC and how the coding guidelines & concepts are applied in real life. In a testing situation, the correct answers are the ones that you can get to on an auditing tool using History, Exam and MDM, because those can be measured and counted on an audit tool whereas the contributory factors can be interpreted differently, and there needs to be a right vs. a wrong answer so you can be graded.

In practice, choosing a 99213 vs. a 99214 for these scenarios is not as clear cut as where you end up on an audit tool. Documenting a Detailed History or Exam is easy for these acute visits. If the provider prescribes antibiotics and this is a new problem, then the MDM will always come out to be Moderate. So the choice often comes down to the nature of the presenting problem.

Any time I discuss this exact scenario with a provider, I ask them, "Does it feel right to bill the second highest established outpatient visit for sinusitis? The same level that we assign for evaluating problems like breast lumps that could be cancerous?" I can honestly say that there's only been one provider who's insisted that they should be 99214's strictly based off prescription drug management and the fact that we're "leaving money on the table", and our coders still end up changing them to 99213's.

And this wishy-washy situation is exactly why the Office/Outpatient Visit code requirements are changing next year! :)
 

twizzle

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Good answer Kate. It really comes down to two criteria...does the client want to include MDM as one of the key components in addition to history or exam? and medical necessity.
Factors like including MDM as one of the key components make perfect sense but not all clients do this leading to note bloat and a level 5 for a patient with a cold which is nonsensical.
Does the client want Rx drug management to always be moderate MDM which is an issue clearly open to debate? As Kate says, does the provider regard someone with a sore throat to be the same risk as someone with an enlarging mass of unknown etiology?
The provider is absolutely correct in coding this as a 99213 based on medical necessity.
 

cnramsey

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I think your provider is correct in choosing a 99213 for this. Yes, this visit can meet a 99214 on an auditing tool, but remember that there are other considerations when determining a level of E/M service. In addition to the three "key components" (History, Exam and MDM), the CPT book also lists "contributory factors" in the E/M Services Guidelines that should also be considered when selecting an E/M level, such as counseling, coordination of care and nature of the presenting problem. No matter how many boxes you can check off on an audit tool, medical necessity is the over-arching criterion for payment, and insurance companies will not like to see a consistent habit of charging 99214's visits for acute illnesses in otherwise healthy patients that have a low risk of mortality or functional impairment without treatment, like strep, conjunctivitis and sinusitis.

Basically, there is a difference between the correct answer for a test like the CEMC and how the coding guidelines & concepts are applied in real life. In a testing situation, the correct answers are the ones that you can get to on an auditing tool using History, Exam and MDM, because those can be measured and counted on an audit tool whereas the contributory factors can be interpreted differently, and there needs to be a right vs. a wrong answer so you can be graded.

In practice, choosing a 99213 vs. a 99214 for these scenarios is not as clear cut as where you end up on an audit tool. Documenting a Detailed History or Exam is easy for these acute visits. If the provider prescribes antibiotics and this is a new problem, then the MDM will always come out to be Moderate. So the choice often comes down to the nature of the presenting problem.

Any time I discuss this exact scenario with a provider, I ask them, "Does it feel right to bill the second highest established outpatient visit for sinusitis? The same level that we assign for evaluating problems like breast lumps that could be cancerous?" I can honestly say that there's only been one provider who's insisted that they should be 99214's strictly based off prescription drug management and the fact that we're "leaving money on the table", and our coders still end up changing them to 99213's.

And this wishy-washy situation is exactly why the Office/Outpatient Visit code requirements are changing next year! :)
Thank you for getting back to us! I do have a few questions regarding this same scenario but the patients Dx is influenza, bronchitis or pneumonia. Our providers are picking 99213 for these types of presenting problems also. One provider has told us she picks a 99213 instead of a 99214 because he O2's in the clinic are fine. So are you saying if the provider picks a 99213 than they are telling us they feel the medical necessity is not moderate and I should leave the 99213. I understand what you guys are saying its just frustrating for us due to webinars we listen to and now AAPC is telling us also that we should be coding a 99214 and it is not our job to say it's medically necessary or not. We are to work it up. I'm feeling even more unsure of how I'm to use what we are studying for in our clinic. Why would AAPC have us counting the bullets one way but than we need to code them in the clinic differently.

Sorry not upset with you guys just feeling like my head is going to explode. :)
 

wisibyusha

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I believe, once you identify the extent of the history, exam, and mdm then the rule will be following the CPT E/M levels paying attention to 3/3 and 2/3. Based on these I tried to break down everything in your SOAP and arrived at 99213.
 

dmunoz781

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I also am coming up with a 99213 due to medical necessity which is should be the overarching criteria when selecting a CPT per CMS, please see citation below.

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r178cp.pdf
 
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cnramsey

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So when working the risk management up for the presenting problem is low 99213 and a Rx is written moderate management 99214. I should always chose the lower element for this section? If my HPI is expanded focused 99213 and my exam is detailed 99214. The sinusitis is new to the provider 99214, data none, risk of presenting problem is low one acute illness 99213 part of this same box is Risk management and provider called in a Rx moderate 99214. But since my presenting is low I should lower my 99214 risk code to a 99213? I know I can’t do this for the AAPC test but your saying what I’m studying I shouldn’t apply in my job. Our administration has us taking this course to educate our doctors. So I’m basically just studying to pass for another certification but will not use it. I literally want to cry! Before the CEMC course I was coding a 99213 for the ie sinusitis with Rx management. I applied this to my practice test in the CEMC course and I failed the study guide test questions. The https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf says you have three boxes that make up the MDM and you need 2/3. Other forums I’m reading others are saying this would support a 99214. 🙃
 
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MDM is key factor , Presenting Problem is one self limited minor problem , which goes go low Moderate even Antibiotic is Prescribed , as kate said above nature of presenting problem is low severity risk of morbidity without treatment is low full recovery is expected . 99213 is justified for the above case
 

katemae84

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I can see why it would be frustrating! To put it bluntly, for your test use whatever you come up with on an audit tool for your answer. In real practice, your instincts of those simple acute problems like strep and sinusitis being a 99213 are generally right. The current documentation requirements and audit tools are pretty outdated as far as clinical guidelines go nowadays, hence why you can get the same visit levels of 99214 for strep throat and potentially cancerous masses...
 

cnramsey

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I can see why it would be frustrating! To put it bluntly, for your test use whatever you come up with on an audit tool for your answer. In real practice, your instincts of those simple acute problems like strep and sinusitis being a 99213 are generally right. The current documentation requirements and audit tools are pretty outdated as far as clinical guidelines go nowadays, hence why you can get the same visit levels of 99214 for strep throat and potentially cancerous masses...
Thank you for understanding my frustration. lol I will definitely being doing exactly what you are suggesting. :) It's just makes no since why we would be studying for a test this way. The test should be set up for how we would code in real practice. Thank you all for your input and help with this.
 
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