I have seen a large variation in how different outpatient offices bill the same type of progress note. If a progress note has a comprehensive history, comprehensive exam and moderate risk/medical decision-making, then technically it should qualify for 99215 cpt code. There is an unwritten rule that auditors seem to lean toward that says the medical decision-making and risk should drive the coding of the note, and if there is insufficient risk to justify the comprehensive history and comprehensive exam, then these components are "medically unnecessary" components and should therefore be coded at 99214 instead. There seem to be several opinions from coders regarding coding of notes with comprehensive history, comprehensive exam and moderate medical decision-making for established patients.
Coder opinion #1 - "An outpatient office should never code a level 5 visit, maximum level is 4. Level 5 visits should be reserved for the emergency room."
Coder opinion #2 - These coders follow criteria exactly and ignore the tendency of auditors to emphasize risk driven codes.
Coder opinion #3 - These coders tend to code about 20 to 30 percent of these visits a level 5, mostly patients with higher risk and decision-making.
I wanted some opinions on how others tend to code (or see coworkers code) the following notes, 99214 vs 99215 in their own experience.
Scenario 1:
History - 3 chronic illnesses or recurrences. Urinary frequency. Bronchitis. Congestive heart failure.
Exam - comprehensive.
Assessment - Given antibiotics for urinary infection (recurrent) and acute bronchitis. Congestive heart failure stable.
Scenario 2:
History - 3 chronic illnesses: Low back pain, congestive heart failure, epilepsy.
Exam - comprehensive.
Assessment - No change in medications. Cong heart failure stable. Epilepsy stable. Wheelchair ordered due to declining gait.
Scenario 3:
History - 3 chronic illnesses: Hypertension, diabetes, constipation.
Exam - comprehensive - agitation noted and somnolence.
Assessment - Antidepressant reduced in dosage due to somnolence. Antibiotic given for suspected UTI pending urinalysis. Hypertension, diabetes and constipation stable.
Scenario 4:
History - 3 chronic illnesses: Congestive heart failure, diabetes, hypertension.
Exam - Comprehensive.
Assessment: Mild congestive heart failure exacerbation with increased edema, mildly reduced oxygen saturation compared to prior visit, diuretics increased. Diabetes suboptimal control but no medication changes. Hypertension stable.
Scenario 5:
History - 2 chronic illnesses - Parkinson disease, urinary frequency. 1 new problem - difficulty swallowing.
Exam - Comprehensive.
Assessment - Dysphagia - swallowing study ordered. Urinary frequency - urinalysis ordered. Parkinson disease - no treatment change.
Any input would be greatly appreciated.
Coder opinion #1 - "An outpatient office should never code a level 5 visit, maximum level is 4. Level 5 visits should be reserved for the emergency room."
Coder opinion #2 - These coders follow criteria exactly and ignore the tendency of auditors to emphasize risk driven codes.
Coder opinion #3 - These coders tend to code about 20 to 30 percent of these visits a level 5, mostly patients with higher risk and decision-making.
I wanted some opinions on how others tend to code (or see coworkers code) the following notes, 99214 vs 99215 in their own experience.
Scenario 1:
History - 3 chronic illnesses or recurrences. Urinary frequency. Bronchitis. Congestive heart failure.
Exam - comprehensive.
Assessment - Given antibiotics for urinary infection (recurrent) and acute bronchitis. Congestive heart failure stable.
Scenario 2:
History - 3 chronic illnesses: Low back pain, congestive heart failure, epilepsy.
Exam - comprehensive.
Assessment - No change in medications. Cong heart failure stable. Epilepsy stable. Wheelchair ordered due to declining gait.
Scenario 3:
History - 3 chronic illnesses: Hypertension, diabetes, constipation.
Exam - comprehensive - agitation noted and somnolence.
Assessment - Antidepressant reduced in dosage due to somnolence. Antibiotic given for suspected UTI pending urinalysis. Hypertension, diabetes and constipation stable.
Scenario 4:
History - 3 chronic illnesses: Congestive heart failure, diabetes, hypertension.
Exam - Comprehensive.
Assessment: Mild congestive heart failure exacerbation with increased edema, mildly reduced oxygen saturation compared to prior visit, diuretics increased. Diabetes suboptimal control but no medication changes. Hypertension stable.
Scenario 5:
History - 2 chronic illnesses - Parkinson disease, urinary frequency. 1 new problem - difficulty swallowing.
Exam - Comprehensive.
Assessment - Dysphagia - swallowing study ordered. Urinary frequency - urinalysis ordered. Parkinson disease - no treatment change.
Any input would be greatly appreciated.