Wiki ortho


Meridian, ID
Best answers
I have an ortho provider that continues to put an E/M levels of 99215, and to get that level he documents that he spent 40 min. w/ patient in couciling and coordination of care..ect. His E/M level is probably only a 99213/maybe a 14 but not a 15. I have coded him down before because of the high levels, that is when he started putting the time down to get the level he wants. I also don't feel that the documentation is there for that high of level. He is very argumentative on the level and he will need proof that he doesn't have the documentation. I have researched and I can not find where I can code down if I don't feel that there is enough documentation to support the level, and when I query him, he is not going to budge.
I am fairly new at all this time spent coding and feel there are some gray areas. I really need some help on this.

Thank you
I suggest you audit his charges. If he is stating everything is a level 5 just because he spent 40 min (or whatever time), add up all the time he says he spent one day. Unless he only sees 10-11 patients a day, I doubt he is spending 40 minutes with each patient. If he sees 20+ a day, and says 40 minutes each, that is approximately 13.5 hours or more.

Good Luck!
Bell Curve

Another thing you could try is running a Utilization Graph (also known as a Bell Curve). I had the exact same problem with an IM provider. You can find the data on the CMS website for orthopedics and run a report that shows how he is billing his charges compared to other providers in the US. When I did that for a provider they were outstanded that their billing was WAY outside of the normal bell curve. You can also tell him that if CMS got wind of that he would most likely be audited. Its hard to explain to them that just because they spend 40 minutes with a patient does not always justify a 99215. The MDM must be there as well. I can get you the website for the info from CMS if you need it.
Provide an audit of the elements of the visit, History , exam , decision making, using the guideline set he uses. In order to upcode a visit we must have total face to face time documented ( some payers are now requesting this a time in and time out style) So if he says he spend 40 minutes with the patient and has a counseling note that expresses what was discussed then figure the visit level if it is a level 3 by audit, that is a 15 minute assessment, 40 minus 15 equal 25 and 25 is more than 50% of total time so the visit could be upcode to the level 5, if the audit reveals a level 4 which is 25 minutes then you do not have 50% left for counseling so the visit cannot be upcoded and must stay as a 4. But then comes the question of should the visit be coded to that level, that is a question that cannot be answered without a look at the documentation.
He can do all he wants to do and spend as much time with the patient as he wants.....but, it all boils down to Medical Necessity. If he was ever audited-which if he keeps billing out 5's-its only a matter of time. I wonder how he would feel when he has to give his money back?:eek: