Wiki Needing Help on E/M 99214

[meganbruce]

One of my physicians LOVES to code 99214 and I mean L O V E S this code. I'm beginning to think that HE thinks this is the only follow-up E/M code for Est. patients!

I am having a difficult time educating him on the excess use of this code, when his dictation doesn't seem to warrant that level. For example:

Pt comes in for a 1wk follow-up. The pt was seen the prior week for a ulcer on his testicle. The patient was prescribed an ointment that was not purchased because it was not covered under his insurance and was too expensive. There were NO changes in the patients condition and the physician noted that he would look for an ointment that was covered under his insurance.

This is ALL that was stated in the assessment, but my physician seemed to think it was ok to perform a detailed history and exam, even though the patient was seen the week prior. Now, I know that 99214 only requires 2 of the 3 key components, but what was the medical necessity of performing ANOTHER detailed history and detailed exam? None as far as I'm concerned, nor do I think the MDM in this case is of moderate complexity.

In another office visit, the pt comes in for refills on her 4 meds. Refills only and my physician performs a detailed history and exam. Mind you, the patient was just seen 30 days earlier... for refill of meds. He is wanting to bill out 99214. Again, what is warranting the detailed history and exam if the CC is for refill of meds? The medications are for hyperlipidemia/hypertension/sinuses... all DX are stated as well controlled with medication. I don't even feel the MDM is moderate for this one.

Am I off my rocker on this? I really could use some advice and or guidance on this. It is so very frustrating.

Thanks!!!!

 

[emhartley12]

The MDM doesn't HAVE to be one of the 2/3 when selecting the appropriate code. However, CMS does require the components of the visit to be medically necessary in order to bill a higher level. That being said, MDM is a direct result of medical necessity. So it's not required, but it is encouraged to use MDM, at least in my experience, as one of the 2/3 elements unless you can substantiate medical necessity elsewhere in the note.

(for example: the patient has a history of multiple other problems leading to a more extensive exam, but these problems aren't directly addressed in the MDM section)