E/M Level

maine4me

Guru
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173
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Yesterday I met with one of our family physicians regarding a recent audit. One of her patient's came in for some neurological changes, and was sent to the ER. When I audited the visit is came to a 99214, the doctor coded it a 5. Her reasoning was that since she sent the patient to the hospital she automatically feels the visit is a 5. My feeling is the visit should be coded based on what is done in the office and her decision making, and that this may not always be a 99215. Am I way off base?
 

kparkhurst

Networker
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Lancaster, NY
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Since medical necessity is the overarching criterion for determing a code level, as long as the presenting problem qualifies as a high level of medical necessity, it would be OK to code 99215. With that being said, this rule should not be used to circumvent meeting documentation criteria - this should be used on rare occasions.
 

mitchellde

True Blue
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Columbia, MO
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Still the documentation must be present to meet the criteria, one single element in and of itself cannot be the sole factor in the visit level. Medical necessity is not the only factor in determining the level of care. You must still meet all the necessary elements of the 99215, the exam must n=be comprehensive, and the MDM must be of high complexity, MDM has 3 criteria, 2 of the three criteria must be of the highest level to qualify for high complexity. If the documentation is not there you cannot just call it a level 5 because the patient was admitted.
 
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