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99213 vs 99214 dispute

  1. #1
    Unhappy 99213 vs 99214 dispute
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    Im having a dispute concerning 99213 vs 99214 with a docter i work for. I code on an EHR system and he will not sign off on my codes because he does not believe im correct. I refuse to down code for fear of being audited and charged with fraud.

    The problem is that the patient comes in for an ear infection, URI, etc. (first visit). I can either choose a selflimited or new visit w/o work up. I dont think these warrent a selflimited because they can not go away on their own, and the provider gives antibiotics. So I have a Moderate MDM, and usually a DT hx and exam (1997 standards are used for this EHR system).

    How do I explain to this doctor that this is a 99214 visit? My boss has even sent out my coding to an outside sorce to get another opinion and they maintain its a 99214.

    His claim is that "CMS clearly states that the documentation supports a code, but the visit determines it."

    Does anyone know of documentation that explains this statement?

  2. #2
    Milwaukee WI
    Default Ultimately the physician is responsible
    Ultimately the physician is responsible for the code reported. You and your manager have done an excellent job of explaining the issue to him, but if the physician feels that the work involved was truly a 99213, I would submit it as 99213 (even though the documentation supports 99214).

    This would especially be true with EHR because it is SOoo easy to document a higher level of service with EHR due to the prompts that may be set up in your system.

    Physicians should be able to overide the automatic assignment of codes to code a LOWER level, if they genuinely feel that is a more accurate reflection of the service performed.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Also, remember that you're probably not going to be charged with fraud for under-coding. The only person who's getting jilted by under-coding, is the physician, since they're not getting paid for all of the work that they've done. Choose your battles - If he really wants to leave money on the table, let him. If he's trying to bill for services that aren't supported by the records (such as over-coding, or billing for undocumented services), then hash it out with him.

  4. #4
    Columbia, MO
    MDM is rather subjective in what is moderate or low complexity. It could be your physician does not see the same complexity of information that you do and in that respect we defer to the physicna and it is not under coding. As long as the criteria is consistently applied then it cannot be under coding just because your definition of moderate complexity of information or moderate number of dx/management options is different from the physicians.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    I appreciate all your responses. I am curious about something . If I ignore the rules of choosing an EM and choose the 99213 because the doctor feels that is what the visit should be, then how am I to choose E/Ms in the future?

  6. #6
    You code based on what you know - you find the right answer, and be able to defend why you think it's right. Keep a notebook with how you would code each encounter and why, and if you come across a situation where you and the doctor have differing ideas, present your case to him in a respectful and logical manner. Focus on the benefits of trusting your expertise (like the extra revenue, in this case), and have professional references available for him to visualize (don't just talk about it), such as material from CMS or another payer, specifically backing up what you are telling him. If in the end, he still doesn't take your advice, then at least you made an honest effort to do what you felt was right, and you have documentation to prove it. Ultimately, it's the doctor's responsibility to make sure that his claims are submitted with information supported by the medical record. Doctors hire certified coders so that they can feel comfortable knowing that they can delegate that task without worrying about consequences that result from someone else's errors.

    All of that considered, some doctors will never be completely comfortable with anyone else's decisions, and wll micro-manage their coders. It's your decision to adapt to that or find other employment. No one would suggest that you abandon your principles and ignore your training.

  7. #7
    Flower City
    Default E/M levels
    Your physician may have digested this CMS guidance below and applies this to the ear infection case. To him the severity of the condition does not warrant the 99214 code even if documentation requirements can support it. The statement "it would not be medically necessary......the volume of documentation......etc.." supports his theory on this. In his judgment an ear infection even treated with a prescription is a level 3 because he compares this in his mind to for example a person with COPD stable and on meds and further workup that is a level 4. When you compare and contrast severity of conditions you can evaluate what is the reasonable level. I think this is in the spirit of what medical necessity means. Subjective for sure.

    Per Medicare's Claims Processing Manual on p. 33 here (

    Ch. 12
    Section 30.6.1 A.

    "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."
    Marianne Wink, RHIT, CPC, ACS-EM

  8. #8
    Thank you all very much, I greatly appreciate the advice. Im the only coder for 7 facilities (40+ providers) and no one to bounce ideas off of. Its a big help to have this forum. Thank you.

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