Question Upcoding questions

sempson

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I have a provider who see's patients for preventive visits and always adds an E/M to the visit. If he discusses anything other than what is in the preventive visit (like HBP, or Med refill) he will add an E/M to the visit. What is the rule for that? Also he codes based on time now. Like shoulder pain and leg stiffness he will code a 99215 due to how much time he spends with the patient. MDM is moderate. Anyway, does anyone know where I can find detailed info on upcoding?
 

haraml7

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So HBP is considered a chronic illness and should be included in the preventative visit. Now if the doctor orders a stress test, or examined the heart more in detail this can be considered "additional work" and an E/M can be billed seperatly (just an example). This also goes for med refill, keeping the patient active with med refills keeps the pt healthy which again would be part of the preventative, unless there is a NEW problem, and full evaluation for this new problem is documented.

Your CPT guidelines tell you that you can bill for a separate E/M if a problem, or abnormality, is significant enough to require additional work. The providers documentation should state this information. As for time, the provider would need to state the time he spent for this seperatly identifiable reason to bill for a separate time based E/M.

I don't have any information on upcoding, but i would look up documentation guidelines for time based coding and see what you get.

P.S. Your hamster is the cutest!
 

thomas7331

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I agree. If the physician is spending significant extra time for the problem, above and beyond what is normally involved in the preventive visit, then the additional E/M is warranted. The documentation should clearly reflect that all elements and all time involved in the 99215 are separate from the preventive services, e.g. should show that the 45 minutes time spent on the 99215 excludes the time spent on the preventive visit.

If the time meets the requirements for the code, you don't need to be concerned that the MDM level is lower than the code requirement because coding allow you to use either time or MDM. Some payers might question why a moderate or lower level problem requires that much time, but that is a medical necessity issue and it would really be up to a peer to make that judgment - it's not something a coder needs to worry about.
 

amyjph

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The documentation must support the work, time, MDM, etc. of each code billed. You don't really need detailed info on upcoding, you have to review the documentation and separate out what is being used to support each code. Depending on the payer and/or edits you would probably require a 25 modifier as well, so the documentation would have to support that. Coding based on either time or MDM is completely acceptable since 2021 for office/outpatient, so as advised above you don't have to worry about specific components or elements or "boxes" being checked.

Upcoding means coding a higher level than is documented in the medical record according to the E/M guidelines for the CPT billed. It would be like coding a level five for an office visit that only has either 15 minutes of time documented or is only low MDM. What you are talking about is separately reporting two distinct E/M codes (preventive & office/outpatient) on the same date.

There are lots of resources about this and most payers have it in guidelines.
https://www.uhcprovider.com/content...-Preventive-Medicine-and-Screening-Policy.pdf - "Preventive Medicine Service and Problem Oriented E/M Service A preventive medicine CPT or HCPCS code and a problem-oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician or Other Qualified Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, UnitedHealthcare will reimburse the preventive medicine code plus 50% of the problem-oriented E/M code. UnitedHealthcare will not reimburse a problem-oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended."
 
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