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Nature of Presenting Problem's Relationship to E&M Level

  1. #1
    Default Nature of Presenting Problem's Relationship to E&M Level
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    I'm looking for clarification regarding the correct definition of "the nature of the presenting problem" and how chronic conditions without current exacerbation relate to the level of evaluation and management service. I've seen providers coding level 5 follow-up office visits for patients with debilitating chronic conditions that are stable with no current complaints. These are conditions like cerebral palsy, cognitive and functional impairment, Ehlers-Danlos syndrome, cystic fibrosis, etc. The physician may document medication changes or recommend new therapy. My understanding is that, regardless of how chronically ill a patient is, if they are currently stable and at their personal baseline, even though that baseline may be a pretty severe impairment, it is not appropriate to code a level 5 for routine follow-up with adjustments to the treatment plan and/or medication management. I've had colleagues argue that the underlying condition itself can be severe enough to complicate medical decision making to the extent that high complexity is supported, even without a current exacerbation, but I am unable to find any guidelines that address this specifically. Both 99214 and 99215 state "usually, the presenting problem(s) are of moderate to high severity". Does "the nature of the presenting problem" refer to the patient's overall or underlying physical condition, or is it specific to the signs/symptoms or concerns present at the time of the encounter only?


  2. #2
    It's true that most payer auditors would likely challenge the coding of a 99215 if the patient presents with stable established problems and the provider has not documented having identified any new issues or exacerbations on exam. But this is really a medical necessity question: if the documentation supports a 99215 based on two of the elements of the history, exam and MDM meeting the highest levels, that is the correct code choice - but whether or not those highest levels were really necessary for the patient's condition is outside of the realm of coding, so I think you're unlikely to find helpful guidelines on this. From a purely coding standpoint, I recommend sticking to the coding guidelines for selecting E&M levels and avoid trying to make an independent decision about what level is best matched to evaluate and treat the patient's presenting problems, especially for complex conditions such as these, since that begins to involve a clinical judgment.

    That said, it's easy to recognize that because we're talking about an established patient here, with established problems, it is a reasonable question as to why the highest level for two out of three elements were really necessary if the provider has not documented any specific reasons for it, so this would be a good discussion to have with the providers - if you're asking it, then an auditor is likely to ask it also. I would ask the providers, if this patient is established, the problems are familiar to them and the documentation suggests that they are stable, why was another comprehensive history or exam needed at this interval, and/or why was the MDM of the highest level? If they have good explanations for this, and feel that their peers would agree that this is correct per the standards of care for those conditions, then you have your answer and can use that information defend the code choice and its medical necessity if needed in an audit, or otherwise work with the provider to include more of that information in the note to make it more clear to a reviewer.

    If, on the other hand, the provider does not have a reasonable explanation and it appears that the documentation of the history and exam have been inflated just for the purposes of getting a higher code, then that should probably lead to a discussion of the fact that they could be vulnerable in an audit. In that situation, I'd recommend looking at your providers' E&M bell curve to see if their usage of 99215 makes them an outlier compared to their peers, and you can find the CMS errors reports and OIG work plans which show clearly that providers with a high usage of this code are targeted for review. But ultimately, in the event that the these codes are reviewed and challenged on the basis of whether or not the presenting problem warranted the highest level of service, it will be up to the providers to justify the medical necessity of that to their peers.

    Sorry for long answer, but hope this may help some.
    Thomas Field, CPC, CEMC

  3. #3
    Columbia, MO
    if the chronic conditions are stable then there is no justification for a level 5 visit. If the chronic conditions severely complicate the management of the patient, then this should be clearly reflected in the documentation and not inferred by the existence of the chronic condition. It really depends on the quality of the note. If the note indicates a follow up with no complaints and the provider is looking at labs and tweaking meds then it may be a level 3. However I have had some come in as level 2 due to scant documentation. And in this day you must watch for cloned information.. I do not count cloned information toward the visit level. Cloned information was infor gathered at an earlier point in time and does not reflect the patient in the here and now. I have had cloned HPI and cloned exam and cloned decision making and sometimes all on the same patient. you can pull over ROS if the provider indicates it was discussed with the patient and no change or add change.
    So it will depend on the quality of the note.. nothing is an automatic.

    Debra A. Mitchell, MSPH, CPC-H

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