Wiki Level 5 Office Visits

[skeeley]

I have a provider that is insisting he was instructed by the ASCO to code all chemotherapy patients a level 5. I find this hard to believe. (FYI...We are seeing the patients in the office setting and not the ones who are administering the chemo. We do write the chemo order. The patient is receiving it outpatient through the hospital). Everything in his note states the patient is stable and doing well. Has anyone else heard this? Many of these patients are seen every 1-2 weeks and I do not see how all these appointments could be a level 5. I have asked the provider for a link or copy of this information but have not received a reply back. Any information anyone has would be greatly appreciated. Thank you!

His actual reply is as follows:

All patients getting chemotherapy would be considered high complexity management. They would all be considered "Drug therapy requiring intensive monitoring for toxicity"

This was a subject that came up at ASCO recently and everyone was surprised about billing them at level 4.

 

[Chelle-Lynn]

There are no office visits that are "automatically" any specific level. You are correct that all E&M services need to be leveled based on history, exam, and MDM. If audited the provider will be held to current CMS E&M leveling guidelines. In addition, billing all chemo patients as a 99205 or 99215 will most likely trigger an audit with the various carriers as this will be outside of the normal bell curve that most carriers use as a guidepost.

Even under the MDM the provider would need to meet one of the following for the level of risk;
· One or more chronic illness with severeexacerbation
· Acuteor chronic illness or injury that poses a threat to life or body
· Abruptchange in neurological status (eg; seizures, sensory loss, weakness)
· Recommends elective major surgery
· Emergency major surgery
· Drug therapy requiring intensive monitoring
· Decision not to resuscitate due to condition

 

[skeeley]

Thank you

He is claiming that since they are all chemo patients they automatically fall under Drug therapy requiring intensive monitoring for toxicity. We saw this patient just one week prior. All is good, no changes. This was just a follow up and no changes were made...no labs ordered.

 

[Chelle-Lynn]

Without seeing the notes, based on what you listed, this does not sound like a level 5. I believe that he has been misinformed.

 

[thomas7331]

He is claiming that since they are all chemo patients they automatically fall under Drug therapy requiring intensive monitoring for toxicity.

It does sound like the provider has misunderstood. "Drug therapy requiring intensive monitoring for toxicity", if supported, does put the patient into the highest category of the table of risk. But high risk does not automatically equate to a level 5. Risk is one element counted toward MDM, and MDM is only one element used to calculate the E&M level. The encounter has to be coded based on the entire note after review of all of the element according to CPT guidelines, not just on the fact that the patient is high risk.

 

[skeeley]

Thank you both. I have these visits flagged for our external auditor to review and discuss with him during our annual audit.