Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Oh I agree, we definitely should not intentionally downcode to avoid scrutiny. Like you, I code what I do & document & because of that have very few 99215's. I also do not intentionally avoid a 99215 if it seemed appropriate (I submit maybe 1 - 2 99215's per month). In my opinion, a 99215/99205 is basically an office emergency type of visit (ie, an acute seizure, ACS, etc). That is why I find it difficult to believe that any single practice could be THAT different in the level of acuity it sees to have a coding curve that is SO far removed from that of their peers. Slightly more 99214's and, say, 5%- 10% 99215's? Yes, maybe. But 50% - 95% 99215's? The coding bell curve is definitely broken (ie, skewed downwards because of chronic undercoding) but is it really THAT far off? Possibly, but I remain skeptical. > > > Date: 2005/08/16 Tue PM 08:06:13 EDT > To: > Subject: Re: 99215 code > > , > I see your point of view, that the expectations of the insurance > companies is that the frequencies of E/M codes should fall into a > nice neat little bell curve. But this implies that there must be some > kind of quota for levels of care or that everyone's practice is the > same, both of which seem unreasonable to me. I can see how one > doctor's practice style might attract a certain kind of patient, such > as those with complicated problem lists and time-consuming > psychosocial issues. This kind of practice might actually see a lot > of 99214's and 99215's. Are you saying that we should deliberately > undercode so as not to attract attention? Isn't that what's been > going on for years already? > > I think we should code accurately and honestly. I don't know who made > up these complicated rules (I hope it wasn't us doctors), but it > seems unreasonable to me to say that we cannot use the rules, not to > exploit or abuse the system, but to receive fair and just > compensation. As it is, I think most of us doctors would agree that > we are not being paid a fair amount for the time and effort we put in. > > As for retaliation, I don't think the insurance companies will junk > the current system to go after a few outliers. That would take a lot > of outliers. Yes, they may lower their fees even more, and then you'd > have to decide if it's worth continuing to accept them as a payor. > And I agree that if you code a lot of 99214's and 99215's, you should > expect to see increased scrutiny and audits from the plans who can't > believe that you are doing what you claim to be doing. If you've done > your job properly, you can back up your charges. And if they reject > your documentation and unilaterally reduce their payment anyways, you > would need to evaluate whether it is worth your time and effort to > file suit. I believe Aetna recently settled a class action lawsuit > accusing them of deliberately downcoding claims, so I don't think > they will be very likely to do that again soon. > > BTW, I have a very bell-shaped curved distribution of my codes, but > it's because that's what I really did, not because I was trying to > avoid coding too many 99215's. > > > > > > > Yes but the other problem with coding that way is that the > > insurance companies will only let that go on for so long & they > > will find a way to get that money back. They are paying out on all > > of those 99215's & you can bet they will find a way to close that > > " loophole " . They will then just lower their " discounted fees " even > > more, stop using E/M codes altogether, etc. Document & code > > appropriately, yes. But to be clear off the graph as a coder (ie, > > >50% 99215's) just seems ridiculous & will only draw further cost- > > cutting measures & scrutiny from the payors. You have to remember > > that even coding the majority of your visits as 99214's is > > considered off the curve & excessive, let alone mostly 99215's. > > Just differing opinions on things I guess. > > > > > > > > > > > > > Date: 2005/08/16 Tue PM 05:42:06 EDT > > > To: > > > Subject: Re: 99215 code > > > > > > I agree that time alone shouldn't be the ONLY determinant for coding > > > a 99215. But the guidelines do state that if more than 50% of the > > > time is used for counseling, it may be appropriate to use amount of > > > time spent with a patient to determine which code to use. > > > > > > Here is a link to an article from Family Practice Management on how > > > to code on the basis of time: > > > http://www.aafp.org/fpm/20030600/27time.html > > > > > > ***** > > > > > > " If a physician spends more than 50 percent of a face-to-face visit > > > counseling or coordinating a patient's care, the physician can code > > > the visit on the basis of time, even if the history, exam or medical > > > decision-making elements are lacking. > > > The " greater than 50 percent " rule > > > > > > It is not unusual to spend a considerable amount of time face-to- > > face > > > with a patient reviewing problems, adjusting medication dosages, and > > > counseling or coordinating care only to find that you do not have > > > enough history, exam or medical decision-making elements to > > support a > > > code that would otherwise be appropriate for a visit of that > > > duration. In other words, you've spent the time, but the points > > don't > > > add up. This is when the " greater than 50 percent rule " applies. > > > > > > When you devote more than 50 percent of your face-to-face time with > > > the patient to counseling or coordinating care, " time may be > > > considered the key or controlling factor to qualify for a particular > > > level of E/M service, " per CPT. To code these encounters, use the > > > code from the appropriate table on page 30 that relates to the total > > > time spent with the patient. For example, if you spent 25 minutes > > > face-to-face with an established patient in the office, and more > > than > > > half of that time was spent counseling the patient or coordinating > > > his or her care, you could use the 99214 code even if you lack the > > > history, exam or medical decision-making elements. " > > > > > > ***** > > > > > > I think the key would be to document in the chart how much time you > > > spent with the patient (I routinely note the time I start and finish > > > with a patient), and to put in the progress note, " More than 50% of > > > the time was spent counseling or coordinating the patient's > > care " . It > > > would probably also help to write a brief description of what things > > > were counseled or coordinated, but I don't know if that's absolutely > > > necessary. > > > > > > So an hour for acne does not necessarily equal a 99215. But if you > > > document you spent more than 50% of the time counseling on correct > > > use and potential side effects of acne medication, as well as > > > contraception, STD prevention, tobacco and alcohol use, diet and > > > exercise for obesity, etc, then a 99215 may be appropriate. > > > Personally I don't use 99205/99215 very often, but I think if you > > did > > > the work AND CAN DOCUMENT IT, then you should be using it. > > > > > > Seto > > > > > > > > > > > > > > > > In regards to the recent discussion on the frequent use of the > > > > 99215 E/M code. I would still contend that spending 1 hour with a > > > > patient just because there are ?issues to be discussed? does not > > > > justify using a 99215, as noted below. As noted, ?usually the > > > > presenting problem (s) are of moderate to high severity? and that > > > > ?medical necessity of a service is the overarching criterion for > > > > payment.? It is just not possible that >50% of any doctor?s > > visits > > > > could be moderate to high complexity (at least not in primary > > > > care). In my opinion, you can discuss 30 items for 2+ hours but > > > > that still does not make it moderate to high complexity. > > > > > > > > > > > > Decision Making and 99215 > > > > Q: The 1997 version of Medicare's Documentation Guidelines for > > > > Evaluation and Management Services states that the code for an > > > > established patient visit can be based on two of the three key > > > > components. But if I perform a comprehensive history and a > > > > comprehensive physical, wouldn't medical decision making of high > > > > complexity also be necessary to code a 99215? > > > > > > > > A: CPT states that " For the following categories/subcategories, > > two > > > > of the three key components (i.e., history, examination and > > medical > > > > decision making) must meet or exceed the stated requirements to > > > > qualify for a particular level of E/M services. " However, it also > > > > states under 99215 that " Usually, the presenting problem(s) are of > > > > moderate to high severity. " Although high complexity medical > > > > decision making isn't required, it's reasonable to conclude that > > > > this level of service may be questioned if it's not present. The > > > > Medicare Claims Processing Manualreminds us that " Medical > > necessity > > > > of a service is the overarching criterion for payment in addition > > > > to the individual requirements of a CPT code. " > > > > > > > > > > > > Source: , CPC writing for Family Practice > > Management & > > > > Medscape Business of Medicine > > > > > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Another thought: if you code someone's lengthy visits with the highest codes available based on time spent, etc then what do you use when someone actually does present in your office with something of high complexity like a new right sided weakness, facial droop, and BP of 240/120? So, somehow that type of visit is on the same level as a 2 hour discussion of multiple problems? It seems to me there has to be a highest level of service that is reserved for the rare very sick patient in the office. Maybe CPT needs a new 99216/99206 level?! Here is a direct quote from Dr. Doug nsen from a recent article entitled " Optimize Reimbursement Via Level 4 and 5 Outpatient Codes. " He is a full time family physician, certified coder, & part owner of a medical consulting business. He says: " Regarding the 99215, this should be a very uncommonly used code. To begin with, you must have a comprehensive history (complete ROS-->10 ROS--and a complete PFSH), a comprehensive exam, and high complexity MDM . . . High complexity MDM typically poses a threat to the life of the patient or is a severe exacerbation of chronic issues. I would recommend caution in using this code. These should be your sickest patient visits and it has been my experience that patients who need this level charge are often hospitalized. " And as you can see from the article's title, this was even intended to help docs maximize reimbursement ( & he yet he still advises caution with this code). I have read his new coding book, several of his articles in medical journals, & even talked to him a couple of times by phone. Believe me, he is all for capturing every dollar you have coming to you & is well aware that most docs in the past have undercoded. Still, he singles out the 99215 code as being distinctly different & to be used very rarely. Re: 99215 code E & M implies " level of service. " I think one problem is that people can't make the same comparison to our " level of service " to a traditional practice (apples and oranges, Yugo vs. Lexus, etc). In a traditional practice, one may discuss two-three problems, but there likely isn't enough time to document them. There also isn't time to " fully " address each problem--more like, let's focus on your diabetes medication, and the other " hand on the doorknob " questions and recommendations are thrown in gratis at the end. I believe, and maybe this is my opinion, that the time qualifier is a safety net for docs who get caught up in a long visit. No, it's not there to be abused, but it is appropriate to catch the " level of service " that went into that visit, versus a 15 minute, level 3 URI visit. I spent two hours with a new patient yesterday. I billed it a new level -205 (my first in 1-2 months), not because of any of the 6 problems we (hopefully) comprehensively covered reached high MDM, but that for an extra " 100 dollars " (or less), the patient probably saved two future visits, and had multiple conditions explained that were never previously understood by her (after decades). This is a frustrating issue, and I want people to be careful not to get into a pattern that I found myself getting into recently: a way of thinking during patient visits that says, " whoa, I'm billing too many -214's here. I know I could keep talking to this patient, but I really need to bill more -213's or -212's, so I'm going to cut them off here. " The insurance company is looking for serious health problems to reach higher codes, but we must remember our " overarching " priority is PATIENT CARE, not playing the statistics game. P.S. I've often felt MDM for a level 5 visit is a myth--the patient would have to be hospitalized to reach such a level, and then one would use admit codes, so.....you're stuck. Of course, I did have one patient who refused admission for a COPD exacerbation---that reached us to a level 5 MDM.... Hope everyone has a nice day Brown, MD Providence Family Health Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Maybe I'm wrong & am in fact still missing out on some opportunities for 99215's. That is why I am interested in hearing other's thoughts. Still, what keeps us then from just not documenting any history, physical exam, med refills, other plan, etc and simply writing a sentence or two, like " Spent 1 hour face to face, 50% was on counseling re: . . . " & just code every visit a 99215 (medico-legal is one reason I realize)? I mean, I'm sure I could force most visits to be an hour+ & could search for & find other " problems " to discuss & document but the question remains: is that good complete care or is it upcoding? I still feel like I do all of the same complete care of multiple medical problems as most others here, I just do it in 25-45 minute visits typically and, like Gordon mentioned in his original articles, my average visit is probably a 99214 (maybe slightly less, between a 99213 & 99214 possibly). Maybe my patient population is just different, but I can not fathom sitting in the room face to face for 2 hours with any single patient no matter how complicated their case. Even in this new model, shouldn't there be a point where you just cut it off & say let's see you back next time? What ever happened to follow up visits? Will patients really gain more from one 2 hour visit than they would in three 20 minute visits (an interesting question I think)? Are patients really hearing you the entire time or are they zoning out in the middle & only remembering the first & last things you said? As a patient, I know I sure would not want to sit in the doctor's exam room for 1-2 hours discussing the intricacies, but that's just me. Re: 99215 code > > E & M implies " level of service. " I think one problem is that people > can't make the same comparison to our " level of service " to a > traditional practice (apples and oranges, Yugo vs. Lexus, etc). In a > traditional practice, one may discuss two-three problems, but there > likely isn't enough time to document them. There also isn't time to > " fully " address each problem--more like, let's focus on your diabetes > medication, and the other " hand on the doorknob " questions and > recommendations are thrown in gratis at the end. > > I believe, and maybe this is my opinion, that the time qualifier is a > safety net for docs who get caught up in a long visit. No, it's not > there to be abused, but it is appropriate to catch the " level of > service " that went into that visit, versus a 15 minute, level 3 URI > visit. I spent two hours with a new patient yesterday. I billed it a > new level -205 (my first in 1-2 months), not because of any of the 6 > problems we (hopefully) comprehensively covered reached high MDM, but > that for an extra " 100 dollars " (or less), the patient probably saved > two future visits, and had multiple conditions explained that were > never previously understood by her (after decades). > > This is a frustrating issue, and I want people to be careful not to > get into a pattern that I found myself getting into recently: a way > of thinking during patient visits that says, " whoa, I'm billing too > many -214's here. I know I could keep talking to this patient, but I > really need to bill more -213's or -212's, so I'm going to cut them > off here. " The insurance company is looking for serious health > problems to reach higher codes, but we must remember our " overarching " > priority is PATIENT CARE, not playing the statistics game. > > P.S. I've often felt MDM for a level 5 visit is a myth--the patient > would have to be hospitalized to reach such a level, and then one > would use admit codes, so.....you're stuck. Of course, I did have one > patient who refused admission for a COPD exacerbation---that reached > us to a level 5 MDM.... Hope everyone has a nice day > > Brown, MD > Providence Family Health > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 17, 2005 Report Share Posted August 17, 2005 Well said. I am learning a lot here. Yes, I agree wholeheartedly that you can not really document too much. I see some of my local colleague's scribbled notes & I just wonder what will ever happen if they are called to court to defend them. Thanks for your feedback. Re: 99215 code > > > > E & M implies " level of service. " I think one problem is that people > > can't make the same comparison to our " level of service " to a > > traditional practice (apples and oranges, Yugo vs. Lexus, etc). In a > > traditional practice, one may discuss two-three problems, but there > > likely isn't enough time to document them. There also isn't time to > > " fully " address each problem--more like, let's focus on your diabetes > > medication, and the other " hand on the doorknob " questions and > > recommendations are thrown in gratis at the end. > > > > I believe, and maybe this is my opinion, that the time qualifier is a > > safety net for docs who get caught up in a long visit. No, it's not > > there to be abused, but it is appropriate to catch the " level of > > service " that went into that visit, versus a 15 minute, level 3 URI > > visit. I spent two hours with a new patient yesterday. I billed it a > > new level -205 (my first in 1-2 months), not because of any of the 6 > > problems we (hopefully) comprehensively covered reached high MDM, but > > that for an extra " 100 dollars " (or less), the patient probably saved > > two future visits, and had multiple conditions explained that were > > never previously understood by her (after decades). > > > > This is a frustrating issue, and I want people to be careful not to > > get into a pattern that I found myself getting into recently: a way > > of thinking during patient visits that says, " whoa, I'm billing too > > many -214's here. I know I could keep talking to this patient, but I > > really need to bill more -213's or -212's, so I'm going to cut them > > off here. " The insurance company is looking for serious health > > problems to reach higher codes, but we must remember our " overarching " > > priority is PATIENT CARE, not playing the statistics game. > > > > P.S. I've often felt MDM for a level 5 visit is a myth--the patient > > would have to be hospitalized to reach such a level, and then one > > would use admit codes, so.....you're stuck. Of course, I did have one > > patient who refused admission for a COPD exacerbation---that reached > > us to a level 5 MDM.... Hope everyone has a nice day > > > > Brown, MD > > Providence Family Health > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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