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pwatson1276

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Hello. I need help discerning what documentation is needed for 99215 based on time and when is it ok to query the provider. I was told today to never ask the provider what made him code a level 5, to just bill what he coded. I want to verify if this is correct.
 
1. What do you think should be documented in order to code a 99215 by time? What does the CPT description state? What would be your proposed E/M level?
2. Does your practice have a policy on querying and/or posing questions to providers?
3. We probably can't assist you with the last part if you have been instructed by your supervisor or manager or a policy internally to "never ask a provider, and bill what they coded." It begs the question of why they have coders at all if that is the case?
 
I guess I'm not certain of the documentation needed to bill the 99215 based only on time. Humana has recouped any claims that were a level 5 based only on time after receiving records. Are there resources you can direct me to that explains what is needed for time? I know medical decision making for level 5, at least what I've seen in pain management is difficult to reach a level 5 visit. I only want to make sure what I send out is correct.
 
pwatson1276 said:
I guess I'm not certain of the documentation needed to bill the 99215 based only on time. Humana has recouped any claims that were a level 5 based only on time after receiving records. Are there resources you can direct me to that explains what is needed for time? I know medical decision making for level 5, at least what I've seen in pain management is difficult to reach a level 5 visit. I only want to make sure what I send out is correct.
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How is the provider documenting time? Vague or non-specific documentation may not stand up on an audit.

This article may be a helpful reference: https://www.aapc.com/blog/88095-accounting-for-time-in-documentation/
 
pwatson1276 said:
I guess I'm not certain of the documentation needed to bill the 99215 based only on time. Humana has recouped any claims that were a level 5 based only on time after receiving records. Are there resources you can direct me to that explains what is needed for time? I know medical decision making for level 5, at least what I've seen in pain management is difficult to reach a level 5 visit. I only want to make sure what I send out is correct.
Click to expand...
Did the payer include any citations or references supporting their recoups? Does the documentation actually meet an established office/outpatient level 5? Is the provider submitting a level 5 for every single patient therefore, becoming an outlier amongst peers in the same geographic area and subspecialty? Is the provider coding every office visit by time only? Is it a "canned" statement and a time template in every note that is not specific to the patient as to the reason the visit is 99215? Is the provider counting time from other activities which should not be counted (e.g., separately reported/billed tests) to try and meet the time requirement to bill the highest level? For 2021 & 2022 40-54 minutes of total time is the threshold. For 2023 the codes were revised and 40 minutes must be met or exceeded.

Is your provider a physiatrist? If so, and your provider is part of any of the specialty societies, they usually have specific coding resources: https://painmed.org/ https://www.aapmr.org/quality-practice/coding-resources

https://www.ama-assn.org/system/files/payer-em-downcoding-resource.pdf (see pg. 11)
CMS: "Medical necessity is the primary reason we pay for a service. It wouldn’t be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is more appropriate."

 
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