99204 billing information

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All,

If you read from the bottom up, you'll see the question I asked that generated this answer from Dr. Necella.

A while back there was some question about billing this code. This is FYI. The only correction that I'd make here is that I didn't necessarily do this as an OBCE issue. I think this could be picked up by our new state association. This would be an excellent seminar to cover correct billing and coding to learn how to get paid for what you do and how to avoid pitfalls of incorrect billing. - MInga

Minga,The "gold standard" for info on E/M comes from a joint document published by the AMA and CMS: 1995 or 1997 Documentation Guidelines for Evaluation & Management Services. (There are subtle differences between the two, but practitioners may choose either). These are the guidelines virtually every third party payer will reference or utilize in E/M decisions.As to the specifics of 99204 billing requirements, likely the DC's posting on the listserv on confusing different issues.There are defined body areas (head, neck, chest, abdomen, groin, back, and each extremity); there are 11 Organ Systems (eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, hematologic/lymphatic, immunologic).Please keep in mind, however, that your choice of examination level should be based on three components (which utilize info from the above body areas/organ systems).

History (which includes CC, HPI, ROS, and PFSH) Examination (of either a single Organ System or Multi-System Examination) Medical Decision MakingYour coding selection is then based on your level of evaluation of these three criteria.There are two potential hazards that many chiropractors face if choosing the 99204 code: First, while it is possible, 99204 indicates that the doctor performed a complete history, including a complete ROS which is typically more extensive than I see taken in most chiro offices. Second, the 99204 code indicates a comprehensive examination was performed that addresses each and every required "bullet" or exam element for whichever specific examination style they choose (may be either Multi-System or Single Organ). Again, many chiropractors are either unaware of the specific bullets they must hit to meet these requirements and/or don't perform this level of examination.Finally, not only does the doctor have to make sure all requirements are met, but they also need to be documented properly!I am glad that OBCE is willing to address this issue, as E/M coding is perhaps the greatest area of potential gain and loss in chiropractic in that most chiropractors are either under-billing (out of fear or ignorance for not knowing how to do it properly) or up-coding (for the latter reason). Either way, this causes the chiropractor to lose revenue that they actually deserved or potentially expose themselves to audit trouble by billing exams that were substandard for the code chosen.I hope this clarifies things.Tom Necela, DC, CPC

On Sat, May 16, 2009 at 8:21 PM, <AboWoman@...> wrote:

Dr. Necela,

there has been some discussion on the listserv lately regarding when to bill for a 99204 exam service. SOme say it's 9 organ systems, others say it's 6 NMS systems. SOme say it's according to the AMA code book, others say it's the CPT chirocode book.

Many are getting denied when billing using 99204. Can you shed light on this topic? And allow me to print it to the listserv? I copied your medicare audit information to both the OBCE and the OCA and I think you'll be contacted regarding setting up a seminar to help docs know what to do in the event of an audit. Thanks in advance,

Minga Guerrero DC

member OBCE

An Excellent Credit Score is 750. See Yours in Just 2 Easy Steps!-- Tom Necela, DC, CPCThe Strategic Chiropractor, LLCTel: (253) 370-6156Fax: (888) 508-8356www.strategicdc.com A Good Credit Score is 700 or Above. See yours in just 2 easy steps!