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Thread: "Advantageous to the provider"

  1. #1
    Join Date
    Apr 2007
    Carmel, New York

    Default "Advantageous to the provider"

    AAPC: Back to School
    I know about this "rule" when it comes to determining whether to use 1995 or 1997 guidelines for the examination. But what about when documenation would support time based coding but the three key elements are documented? A record I was auditing was coded as 99213 by the provider and this was correct when using the three key elements. However, the time spent counseling (which was done as well as the Hx, Exam and MDM), total time spent with the patient, and the nature of the counseling was ALSO documented and if this was coded based on time, it would be 99214. So, which should it be? Not which would we WANT - of course, 99214. But did was it an "error" to use 99213? Or, does the "most advantageous to the provider" rule apply?


  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    was total time spent with the patient documented? if so then subtract the visit level you sya it was a 99213 from the total time spent, the book says a 99213 is 15 minutes so if total time is 25 minutes the visit level is a 99213 so subtract 15 from the 25 and you have 10 minutes left for the counseling which is not more than 50% of total time so the visit remains a 99213. To code based on time total time face to face with the patient must be documented, not just the counseling time.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    Carmel, New York

    Default Yes, total time was documented

    Pulled out the note - in addition to the EPF HX, EPF exam and Low MDM, documented that spent 15 minutes counseling and 30 minutes total time with pt. So, yes, MD does have total time documented. Plus, that is a realistic time - the three elements could certainly have been done in the 15 minutes, and this must have been ADDITIONAL time counseling that was documented.

    This isn't so much of a billing question, but our docs do get evaluated on their coding accuracy since they do it on their own, and we actively monitor and audit. Hence the reason for my question if the doctor is "correct" with 99213.

  4. #4
    Join Date
    Apr 2007


    I have to respectfully disagree with Deb on this one.

    Just because you have elements documented doesn't mean you have to count them if time is documented. It is one or the other, you don't need to subtract anything on this on.

    If time was documented and it supports 99214 that is what you go with. It does not matter what the key components support.

    Most advantageous to the provider is referring to the money, whichever set of guidelines gets them the most reimbursement for that visit, not their correct coding percentage on an audit. It is the same thing with key components versus time, whichever gets the higher level of service is what you use. As long as it is medically necessary.

    Providers get in trouble for undercoding too, not just overcoding.

    Laura, CPC, CPMA, CEMC

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