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Level of Service/Criteria

  1. #1
    Exclamation Level of Service/Criteria
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    A question was raised yesterday in our office regarding review of system /level of service/criteria. I work for a sleep clinic/pain clinic and our normal level is 99211. We are trying to determine how we can do higher levels and still remain legal. We have never done a complete review, but want to include that in our exam. One of the nurses is concerned that if we, for example, do a review of systems, and something comes up, we would be required to treat the patient. My thoughts are, since we are a specialist, if there is a concern that we are not capable of treating, we would refer the patient back to their primary care physician.


  2. #2
    Columbia, MO
    for what reason are you using the 99211? If the patient has already been examined and referred to your clinic for the purpose of a sleep study/ pain amnagement then there is no visit level just your diagnostics/procedures.

  3. #3
    We see patients in the office as well as doing procedures. We see patients in the office on Tuesday,Wed,Thursday and do procedures on Monday & Friday.

  4. #4
    Columbia, MO
    So I am curious then as to the nature of the 99211. If the physician sees and examines the patient then why doesn't his/her documentation meet a higher level? Can you describe briefly an encounter where you would code as 99211?

  5. #5
    Most of our patients come in every 30 days for a medication refill because we prescribe narcotics and we do random drug screens on all of patients. We do an exam on all of our patients, but our physician isn't the best documenter in the world, so I am trying to educate him that if it isn't written down, it didn't happen.

  6. #6
    Columbia, MO
    In an article written for decision health, the compliance officer for CMS wrote several examples of a 99211 and med refills was one that was described, however she was referencing med refills by ancillary personnel not the physician. You can do this as a 99211 for non physician personnel to see the patient and get the refill as long as it is not a complete med refill, in other words if it is time for a review to see if the med should be continued then that is a physician level visit and you will need better documentation to achieve higher levels. I hope you are successful in talking with him!

  7. #7
    What do you mean complete review?

    99212 requires a chief complaint
    PF history (1-3 elements of HPI, no ROS or PFSH is required)
    PF exam (1-5 bullets for 97 DG)
    SF mdm
    Being established it would be 2 out of those 3 to determine the level.

    99213 requires a chief complaint
    EPF history (1-3 elements of HPI, 1 ROS, and no PFSH is required)
    EPF exam (6-11 bullets for 97 DG)
    LC mdm

    I have no idea what your documentation looks like but based on my experience with that type of visit, there should be no problem supporting 99212 and a lot could be 99213. The main difference will probably come down to mdm, whether it is established stable (1pt) or established worse (2pt).

    Just my thoughts,

    Laura, CPC

  8. #8
    Columbia, MO
    Thats what I meant I stated it badly, sorry for that. I was going for documentation that would exceed "patient here for medication review". Which I know I have seen documented even though it was a physician encounter, and if this is what she is seeing then it is a 99211. But yes I agree with you on the visit level.

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