Wiki One of the doc has asked me ...please help


Lindenhurst, NY
Best answers
"could you give us some context (to help us better understand the importance) and illustrate the difference between all these different codes in a more tangible or relatable way (e.g. how much money are we losing out if we only bill a 99283 vs 99284 or 99285? why should we care if we can't bill a 99284 or 99285? why is it that much more important to document in a way that lets you bill for 99284 or 99285?)."

Thanks for any inputs!

99283 is for moderate severity and 99284 is for high severity. Put the code that fits the patients problem and you can't pick for reimbursement. You want your code to match your notes. I don't know if it helps maybe someone in auditing can clarify.
If you look at data then and not dollars, the codes we report are collected as data by payers and other agencies, this data helps to establish trends for your physician, and for the type of practice or facility you are. The data reported by one clinic I worked with is what caused the state to reclassify the clinic as a level V trauma center instead of a physician clinic. This in turn allows for different amounts of reimbursement and certain government assistance to be rendered. So it is important that the documentation be as complete as it needs to be and the codes match the documentation. you do not want to be shown as delivering a level 3 service for an acute MI. I tell my clients to always remember that the severity of illness communicated by the dx code must match the intensity of the service provided, you also would not want to deliver a level 5 service for a sore throat.
I hope this will help a little bit.
It's a bit of a fine line - you don't want to give them rules for all really boils down to medical decision making...but if the other documentation requirements are not met, then you end up having to downcode - and that will cost the facility money.

It's not obvious to the providers why we need the extra information in ROS and PE to jump from a level 4 to a level 5, for example - sharing your basic audit tool with them might help. The key concept I try to get across with my providers is - "if you don't write it, I can't code it" - so even if I know the patient came in with chest pain and was admitted - I can't justify a level 5 unless they let me in on the thought process that made that the right course of action. As I'm a coder/auditor and not a doctor/PA/or Nurse - they have to give it to me in the format I can use.

if your facility uses the T-system - they have some very good educational materials that might help your providers better understand documentation requirements.