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Not sure if a Doctor is upcoding

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I know a Doctor that uses a chart he got from his residency and it leads him to billing many 99205 visits. I am trying to figure out if he is up coding without realizing it.

He goes off of three things: chief complaint is new to him, but may not be new to patient; medical records reviewed (in front or not in front of patient) and Medical Decision Making. If he prescribes opiates then he thinks he can raise the office visit due to high complexity MDM.

So we often get 99205 for a two diagnosis patient with just myofascial pain and high drug monitoring, while the provider only spent 30 minutes with the patient face to face.

Is this right?


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You need to study up on the Marshfield grid method. That's where the answer is, complexity of Medical Decision Making, Amount and /or complexity of Data Reviewed, and Risk of Complications Morbidity and/or Mortality.


True Blue
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I see two issues here:

One is whether or not he is getting a high complexity MDM. To check this, use the guide recommended by kak6 or see Part C (DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING) in the CMS guideline. (Go to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html and choose the 1995 or 1997 "Documentation Guidelines for Evaluation and Management Services" link.)

The other issue is that to get a 99205, he also must be documenting a comprehensive history and comprehensive exam. Is he doing that? (See the same link for guidelines on those issues, too.)