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Please help...

  1. #1
    Greeley, Colorado
    Question Please help...
    Exam Training Packages
    I am so frustrated. I just came back from going over an E/M documentation audit with one of my FP's. Her audit was great...but then she told me that she doesn't code any of her Medicare patients at preventive, all as 99215. Why? Because she is addressing multiple issues for them on a yearly basis. We went in circles, she still doesn't understand how Medicare can tell her a visit like this is not problem oriented, when she lists each out. They are for the most part stable and no changes, just rx refills and blood work (which is the patients normal state of health). Occasionally one might be uncontrolled HTN or DM, which I tried to explain that she could carve out of 99397 (as well as G and Q codes). I can't get through to her. Does anyone have any suggestions? BTW - another physician told her to code this way!!
    Lisa Bledsoe, CPC, CPMA

  2. #2
    I would be concerned that every Medicare patient of hers is being billed at 99215. This clearly is almost an impossibility, and you might want to let her know that carriers have sophisticated software that searches for "impossibilities" like this. If they detect a pattern, they will pull all of these and audit themselves, and I can almost guarantee they will not find they are all 99215's! After downcoding and requesting refunds, they will probably flag all E&M's going forward. After that, EVERYTHING is scrutinized and held up for payment. This is probably not something she wants to happen.

    Also, you could remind her that coding is the reporting language of medicine, just as clinical documentation is the recording language of medicine. Just as she wouldn't chart something that wasn't performed, she shouldn't code something that is not supported by the documentation. I suspect she may be coding higher because she feels like this is "fair" compensation for her time. While I sympathize with her, because I realize geriatric patients tend to have multiple issues, this isn't how E&M coding works. She can only code what the documentation supports.

    Finally, she may have some Medicare patients that qualify for this code. Remind her to chart how much time is spent in counseling. Particularly with Medicare patients that sometimes require a lot of counseling, this may get you to a higher E&M level based on time.

    Hope this helps, and good luck!



  3. #3
    Columbia, MO
    The end result thought is regardles of time spent a preventive exam is never a 99215 it is a preventive and just because it is not covered by Medicare does not mean that we charge it as anything other than what it is. So to charge a preventive as a level 5 to get Medicare to pay rather than the pateint would be called that nasty little f word.... fraud.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    I have had this issue with many providers. It comes down to the intent of the visit. Is it truly a preventive nature and the chronic issues are not really being addressed (only notated in Past Medcial History)? If it truly is a preventive visit and not a visit to address thier multiple concerns than I say you have to report a preventive based on the documentation - with women you possibly have the carve out G/Q codes if documentation supports which will lower the cost for the patient.

    If the intent is a full comprehenisve follow up to go over and address the chronic medical problems and a comprehsnive exam performed is medically necessary and relevant for the chronic problems that the patient has then you may have a level 4 (possibly 5 but not usually) based on history, exam and MDM.

    The other scenario that I would often see is a patient who has HTN and Hyperlipidemia - these conditons to not really warrent a comprehensive exam but if they are addressed and managed during a visit that is also preventive in nature you can have the 99397 and appropriate problem visit carve out (i.e. 99213) for the work done in addressing the HTN and Hyperlipidemia (if history and MDM are documeted to support). You may also have the G/Q code carve outs to further reduce pateint out of pocket expense.

    In short - the provider needs to document up front in chief complaint the "intent of the visit" it a preventive visit, a medically necessary visit warrenting comprehensive history and exam for multiple chronic conditions or a combination of both. If it is the 2nd scenario (medically necessary visit for chronic condition) then the doucmentation needs to reflect this by adding in relevant HPI for those conditions.

    If this provider feels that these visits are for follow up of chronic conditions than make sure she indicates this in the chief complaint. Also - each patient is unique and cannot say that these are all "level 5's" - it will all depend on the conditions being addressed and medical necessity.

    Hope that helps. I have been dealing with this issue for years and I feel your pain.

    Christie Musser, CPC

  5. #5
    Greeley, Colorado
    Red face
    Thank you all for your input. I just can't seem to get it into her head what we are all saying. She doesn't understand how anyone can consider yearly follow up on a Medicare patient with multiple co-morbidities yet stable as preventive. I'm at a loss and feel like I'm just not doing my job correctly.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Default new patient visit
    I am having the same problem. This doctor codes new patient visit with a cc of "establish as patient". It is a physical, with the patient refusing treatment to the multiple long time ailments.

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