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Mohs Consults E/M - 99214

S

Sarahp941

Networker
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45
Location
Bradenton, FL
Hello! I have a question about MDM for Mohs consults. We have 20 Providers in my Practice with 2 Mohs surgeons. Our Mohs surgeons like to do consults since they are not the original Provider performing the biopsy or originally evaluating the patient. During the consult, they examine the lesion(s), match the proper anatomical location to Pathology report (correct if needed) and discuss potential closure options (complex, flaps, grafts, ear wedges, etc.). With that being said, the Mohs surgeons think they should get 99214, even if a "major repair" is not discussed. I am having a little difficulty justifying a Moderate complexity just because it's Mohs. We use Modernizing Medicine (EMA) as our EMR system and there are boxes within the template to check off, which of course drives the CPT coding based on what is selected. Can anyone provide some clarity on how you could Mohs consults or if these consults really are justified as a level 4 based on the fact that it's Mohs? Any advice is welcomed. Thanks in advance :)
 
Each individual E/M service needs to be coded based on the documentation provided. The simple reason that it is "Mohs" does not automatically make it anything.
The reason my docs no longer code and we use a certified coder is because their rationale was "every patient is level 5 - I'm a cancer surgeon."
You need 2 of 3 elements of MDM to code a particular level. Problem, data and risk.
All that being said, below is my GENERAL overview. Notice the use of "likely" everywhere which means you still need to evaluate each note to determine the level.
Regarding problem - if there was already a biopsy that came back not great, you are likely at moderate (level 4) for problem.
Data - likely minimal or none. Unless your Mohs surgeons are credentialed differently than your dermatologists, you cannot count data for another physician of the same specialty in the same group to review the findings again. Even if you can count the pathology review, that is still likely only 1 data point. Likely minimal or none (level 2) for data.
Risk - likely moderate. If they are discussing the risks of an incisional biopsy and types of repair, I would count that as moderate (level 4 risk). If they are discussing a major surgery and risks, then risk would be high (level 5).
So, LIKELY often 99214. But certainly not always. Coding depends on the documentation.

Let me just get on my soapbox and address one other item. You use the word "consult" many times in your question. Consult in the context of medical coding is very different than what most clinicians call a consult. Since this is a medical coding forum, I would advise to not use the word "consult" unless that is what you actually mean. The misunderstanding, overuse, and abuse of consult E/M codes is why they are basically done away with. I doubt the 3Rs (request, render & reply) apply to these visits. Clinicians use the word consult as a general term simply meaning another physician asked them to see the patient. Not to mention, IF the visit is actually a "consult" by coding definition, you must level not just by MDM, but by history, exam and MDM with 1995/1997 guidelines (for now).
 
Christine could not have given you a better answer. Kudos Christine ! It sounds like your letting the EMR choose the E/M code. While the information from the EMR can be beneficial, a properly trained certified coder should be making the final decision if the E/M code is correct or not. When our company went from charts to an EMR I worked with the EMR team to get the EMR to choose the correct E/M level. The problem was is that there are too many variables and the EMR could not be accurate enough to count on. In MOH's the doctor is treating skin cancer. So I can see where 99214 is probably going to be accurate much if not most of the time, but as Christine has pointed out, this is not a given. The documentation has to support the code. Keep in mind all coders are growing and learning no matter how much experience they have. Christine has given you some great coding advice to follow. You'll be fine.
 
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