Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Addendum to last e-mail: in the physical, if you did 3 vital signs (BP, temp, pulse), that counts as 1 element Also, I meant to include this - the link for Family Practice Managment, which contains the E/M Coding Guidelines: How to Get All the 99214s You Deserve -- Family Practice Management - October 2001 http://www.aafp.org/fpm/20011000/43howt.pdf Same article reprinted in October of 2003 – available at http://www.aafp.org/fpm/20031000/31howt.pdf The article talks about level 4 visits, but also contains a table that lists the required documentation for all levels of visits. Note, for an “established” patient, you need 2 out of 3 components, for “new” patient you need 3 out of 3 components. > >Reply-To: >To: >Subject: RE: " Overcoding issues " >Date: Wed, 01 Feb 2006 06:37:25 +0000 > >Your example of a 17yo female with a sore throat could have easily been a >99203. Here's why: > >Hx - You've got the chief complaint; HPI only needs 1-3 elements, which >you >have; you only need pertinent ROS - such as fever, ear pain, other URI >symptoms (which presumably you asked about - since you've state " no other >complaints " ) > >PE - you don't need a head-to-toe exam for a Level 3 visit, you just need >at >least 6 elements: ears, nose, throat, Lymph nodes, heart, lungs are 6 (but >you could also easily justify abdominal exam as mono is on the >differential, >esp in this age group and splenomegaly would be pertinent) > >Decision-making: Checking a throat culture and deciding whether or not to >use antibiotics justifies " low " decision-making. > >All that I've described is pertinent and justifiable, so coding for a 99203 >would not be fraudulent, nor unnecessary. > >Debbie >New Jersey > > > > > > >Reply-To: > >To: < > > >Subject: RE: " Overcoding issues " > >Date: Tue, 31 Jan 2006 11:15:07 -0500 > > > >A good representative example: I just saw a 17 yo female as a new patient > >this AM. CC was sore throat of 3 days duration, getting slightly worse. > >Absolutely no other complaints, on no meds, otherwise healthy. Rapid >strep > >test done, RX written. Gave patient education handout from MDconsult on > >pharyngitis. Code: 99202. For me to try to document a head to toe exam >to > >make that a 99203 or higher would be fraud in my book. Sure, my > >history/ROS > >may be there but not the MDM or necessity. > > > > > > > > " Overcoding issues " > > >> > > >> > > >>I have been following this group and have learned a lot. I appreciate > >all > > > > >>of the advice! I have a question with which I would like some help. > > >> > > >> > > >>I recently received a letter from one of our larger HMO's that said >my > > >>coding was above average for Family Medicine physicians, comparing > >their > > >>2004 data to my 2005-as it related to 99214-15's. They said that they > >are > > > > >>going to monitor my billing and, if that trend continues, they will >be > > >>auditing my records. > > >> > > >> > > >>My initial thoughts-I know that many of us previously downcoded to >13's > > >>so as not to have to think or document, or to avoid just such >letters. > >I > > >>also know that the " bell curve " is moving upward because we are now > > >>becoming more proficient in coding, so the published data from even a > >few > > > > >>years ago is not accurate now. I am just starting up (1.5 years in >this > > >>practice). I only have about 75 patients in my panel for this > >particular > > >>group, and, in this short time frame, it has been mainly the more > > " sick " > > >>patients that are coming in. I am getting many chronically ill >patients > > >>with numerous problems, from our other ambulatory sites (I am >hospital > > >>employed), and, although these pts. are new to me, I have to bill >them > >as > > > > >> established because all of the sites have the same Tax Id, and >these > > >>pts are all considered established. Needing to cover so many issues >at > > >>the " new " visit obviously results in many (mostly) 99214's. > > >>Realistically, I feel that my panel is not large enough to have even > > >>developed enough data for a " normal " bell curve, but I could be just > > >>rationalizing all of this to support my data! > > >> > > >> > > >>My question-should I be pro active and contact the medical director >of > > >>this HMO who sent the letter to discuss this, find out the time frame > >for > > > > >>their previous monitoring, and do my own audit of my charting? And if > >my > > >>charting supports my billing pursue this to " prove " to them I am >coding > > >>appropriately (if my charts verify this)? Or should I not worry about > >it, > > > > >>just be sure to focus particularly on this group to make sure I do > >things > > > > >>appropriately in the future. I hate to just let this go because I >feel > > >>they are sending out letters like this just to scare us into > >downcoding. > > >>My best friend is the compliance officer for a nearby hospital > > >>ambulatory care center, doing all of their auditing, and she also >works > > >>for a company that does just such audits nationwide. She has audited >my > > >>charting previously, at my request, and tells me I am doing things > > >>appropriately. But I hate to " tick off " this company and their >director > > >>and forever have the spotlight on my practice. By the way, I do not > >have > > >>EHR; we use only paper charts with hand written notes. I have used >the > > >>StatCoder program on my PDA and find that, according to that, my >coding > > >>is appropriate, although some issues like medical decision making, >can > >be > > > > >>somewhat grey areas. > > >> > > >> > > >>Any ideas would be appreciated. > > >> > > >> > > >>Sue > > >> > > >> > > >> > > >> > > >> > > >>YAHOO! GROUPS LINKS > > >> > > >> Visit your group " " on the web. > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 You say 99202. I say 99203. Potato. Po-tah-toe. Tomato. To-mah-toe.This discussion illustrates the variation and subjectiveness involved in medical coding. It is more art than science, and studies have shown wide variability among coders when evaluating the same visit. This article from Family Practice Management discusses some of this: Are You Prepared to Defend Your Coding? http://www.aafp.org/fpm/20050600/17arey.htmlAn excerpt:"In 2000, the Journal of Family Practice published a study (http://www.jfponline.com/Pages.asp?AID=2559 & UID=) in which four faculty physicians, six resident physicians and six professional coders audited 1,069 charts.1 The results indicated that professional coders agreed with the codes assigned by the physicians far more often than did the physician or resident auditors. Further, when auditors disagreed with a code selection, the documentation justified a higher level of service four times more often than it suggested a lower level of service.Another recent study involving a review of E/M codes assigned to 125 visits by pediatricians found that 44 percent of the visits were undercoded and 1 percent were overcoded.2 Before correction of the undercoding and overcoding, the code distribution showed a bell curve with the predominance of claims at the midlevel (99213). After correction based on the proportion of error found by the independent review, a more equal distribution of midlevel (99213) and upper level (99214) codes was demonstrated.In a third study, 600 family physicians were sent surveys asking them to assign codes for six different clinical scenarios.3 The 205 physician responses agreed with expert CPT E/M code assignment in 52 percent of the scenarios for established patient visits. Undercoding was the most common error, identified in 33 percent of the cases. Again, the bell curve showed a more equal distribution of codes 99213 and 99214 after correct coding was applied.These studies indicate that coding of E/M services is not a clear-cut process. Physicians have difficulty choosing correct codes for these services based on the guidelines available, and even trained coders often disagree."--------------It's a nutty and flawed system, in my opinion, which makes it all too easy to make assessments that can later be branded as "errors" or "fraud". It does not improve medical care, but merely forces doctors to jump through a few more hoops in order to get paid. That being said, I will do my best to understand the system in order to maximize the reimbursement which does not sufficiently compensate physicians for all the work we do. I will play the coding game until something better comes along. SetoSouth Pasadena, CA Your example of a 17yo female with a sore throat could have easily been a 99203. Here's why: Hx - You've got the chief complaint; HPI only needs 1-3 elements, which you have; you only need pertinent ROS - such as fever, ear pain, other URI symptoms (which presumably you asked about - since you've state "no other complaints") PE - you don't need a head-to-toe exam for a Level 3 visit, you just need at least 6 elements: ears, nose, throat, Lymph nodes, heart, lungs are 6 (but you could also easily justify abdominal exam as mono is on the differential, esp in this age group and splenomegaly would be pertinent) Decision-making: Checking a throat culture and deciding whether or not to use antibiotics justifies "low" decision-making. All that I've described is pertinent and justifiable, so coding for a 99203 would not be fraudulent, nor unnecessary. Debbie New Jersey > >Reply-To: >To: < > >Subject: RE: "Overcoding issues" >Date: Tue, 31 Jan 2006 11:15:07 -0500 > >A good representative example: I just saw a 17 yo female as a new patient >this AM. CC was sore throat of 3 days duration, getting slightly worse. >Absolutely no other complaints, on no meds, otherwise healthy. Rapid strep >test done, RX written. Gave patient education handout from MDconsult on >pharyngitis. Code: 99202. For me to try to document a head to toe exam to >make that a 99203 or higher would be fraud in my book. Sure, my >history/ROS >may be there but not the MDM or necessity. > > > > "Overcoding issues" > >> > >> > >>I have been following this group and have learned a lot. I appreciate >all > > >>of the advice! I have a question with which I would like some help. > >> > >> > >>I recently received a letter from one of our larger HMO's that said my > >>coding was above average for Family Medicine physicians, comparing >their > >>2004 data to my 2005-as it related to 99214-15's. They said that they >are > > >>going to monitor my billing and, if that trend continues, they will be > >>auditing my records. > >> > >> > >>My initial thoughts-I know that many of us previously downcoded to 13's > >>so as not to have to think or document, or to avoid just such letters. >I > >>also know that the "bell curve" is moving upward because we are now > >>becoming more proficient in coding, so the published data from even a >few > > >>years ago is not accurate now. I am just starting up (1.5 years in this > >>practice). I only have about 75 patients in my panel for this >particular > >>group, and, in this short time frame, it has been mainly the more >"sick" > >>patients that are coming in. I am getting many chronically ill patients > >>with numerous problems, from our other ambulatory sites (I am hospital > >>employed), and, although these pts. are new to me, I have to bill them >as > > >> established because all of the sites have the same Tax Id, and these > >>pts are all considered established. Needing to cover so many issues at > >>the "new" visit obviously results in many (mostly) 99214's. > >>Realistically, I feel that my panel is not large enough to have even > >>developed enough data for a "normal" bell curve, but I could be just > >>rationalizing all of this to support my data! > >> > >> > >>My question-should I be pro active and contact the medical director of > >>this HMO who sent the letter to discuss this, find out the time frame >for > > >>their previous monitoring, and do my own audit of my charting? And if >my > >>charting supports my billing pursue this to "prove" to them I am coding > >>appropriately (if my charts verify this)? Or should I not worry about >it, > > >>just be sure to focus particularly on this group to make sure I do >things > > >>appropriately in the future. I hate to just let this go because I feel > >>they are sending out letters like this just to scare us into >downcoding. > >>My best friend is the compliance officer for a nearby hospital > >>ambulatory care center, doing all of their auditing, and she also works > >>for a company that does just such audits nationwide. She has audited my > >>charting previously, at my request, and tells me I am doing things > >>appropriately. But I hate to "tick off" this company and their director > >>and forever have the spotlight on my practice. By the way, I do not >have > >>EHR; we use only paper charts with hand written notes. I have used the > >>StatCoder program on my PDA and find that, according to that, my coding > >>is appropriate, although some issues like medical decision making, can >be > > >>somewhat grey areas. > >> > >> > >>Any ideas would be appreciated. > >> > >> > >>Sue > >> > >> > >> > >> > >> > >>YAHOO! GROUPS LINKS > >> > >> Visit your group "" on the web. > >> > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Then give me an example of what would constitute a 99201 and a 99202. There are 5 levels for a reason. " Overcoding issues " > >> > >> > >>I have been following this group and have learned a lot. I appreciate >all > > >>of the advice! I have a question with which I would like some help. > >> > >> > >>I recently received a letter from one of our larger HMO's that said my > >>coding was above average for Family Medicine physicians, comparing >their > >>2004 data to my 2005-as it related to 99214-15's. They said that they >are > > >>going to monitor my billing and, if that trend continues, they will be > >>auditing my records. > >> > >> > >>My initial thoughts-I know that many of us previously downcoded to 13's > >>so as not to have to think or document, or to avoid just such letters. >I > >>also know that the " bell curve " is moving upward because we are now > >>becoming more proficient in coding, so the published data from even a >few > > >>years ago is not accurate now. I am just starting up (1.5 years in this > >>practice). I only have about 75 patients in my panel for this >particular > >>group, and, in this short time frame, it has been mainly the more > " sick " > >>patients that are coming in. I am getting many chronically ill patients > >>with numerous problems, from our other ambulatory sites (I am hospital > >>employed), and, although these pts. are new to me, I have to bill them >as > > >> established because all of the sites have the same Tax Id, and these > >>pts are all considered established. Needing to cover so many issues at > >>the " new " visit obviously results in many (mostly) 99214's. > >>Realistically, I feel that my panel is not large enough to have even > >>developed enough data for a " normal " bell curve, but I could be just > >>rationalizing all of this to support my data! > >> > >> > >>My question-should I be pro active and contact the medical director of > >>this HMO who sent the letter to discuss this, find out the time frame >for > > >>their previous monitoring, and do my own audit of my charting? And if >my > >>charting supports my billing pursue this to " prove " to them I am coding > >>appropriately (if my charts verify this)? Or should I not worry about >it, > > >>just be sure to focus particularly on this group to make sure I do >things > > >>appropriately in the future. I hate to just let this go because I feel > >>they are sending out letters like this just to scare us into >downcoding. > >>My best friend is the compliance officer for a nearby hospital > >>ambulatory care center, doing all of their auditing, and she also works > >>for a company that does just such audits nationwide. She has audited my > >>charting previously, at my request, and tells me I am doing things > >>appropriately. But I hate to " tick off " this company and their director > >>and forever have the spotlight on my practice. By the way, I do not >have > >>EHR; we use only paper charts with hand written notes. I have used the > >>StatCoder program on my PDA and find that, according to that, my coding > >>is appropriate, although some issues like medical decision making, can >be > > >>somewhat grey areas. > >> > >> > >>Any ideas would be appreciated. > >> > >> > >>Sue > >> > >> > >> > >> > >> > >>YAHOO! GROUPS LINKS > >> > >> Visit your group " " on the web. > >> > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Then give me an example of what would constitute a 99201 and a 99202. There are 5 levels for a reason. " Overcoding issues " > >> > >> > >>I have been following this group and have learned a lot. I appreciate >all > > >>of the advice! I have a question with which I would like some help. > >> > >> > >>I recently received a letter from one of our larger HMO's that said my > >>coding was above average for Family Medicine physicians, comparing >their > >>2004 data to my 2005-as it related to 99214-15's. They said that they >are > > >>going to monitor my billing and, if that trend continues, they will be > >>auditing my records. > >> > >> > >>My initial thoughts-I know that many of us previously downcoded to 13's > >>so as not to have to think or document, or to avoid just such letters. >I > >>also know that the " bell curve " is moving upward because we are now > >>becoming more proficient in coding, so the published data from even a >few > > >>years ago is not accurate now. I am just starting up (1.5 years in this > >>practice). I only have about 75 patients in my panel for this >particular > >>group, and, in this short time frame, it has been mainly the more > " sick " > >>patients that are coming in. I am getting many chronically ill patients > >>with numerous problems, from our other ambulatory sites (I am hospital > >>employed), and, although these pts. are new to me, I have to bill them >as > > >> established because all of the sites have the same Tax Id, and these > >>pts are all considered established. Needing to cover so many issues at > >>the " new " visit obviously results in many (mostly) 99214's. > >>Realistically, I feel that my panel is not large enough to have even > >>developed enough data for a " normal " bell curve, but I could be just > >>rationalizing all of this to support my data! > >> > >> > >>My question-should I be pro active and contact the medical director of > >>this HMO who sent the letter to discuss this, find out the time frame >for > > >>their previous monitoring, and do my own audit of my charting? And if >my > >>charting supports my billing pursue this to " prove " to them I am coding > >>appropriately (if my charts verify this)? Or should I not worry about >it, > > >>just be sure to focus particularly on this group to make sure I do >things > > >>appropriately in the future. I hate to just let this go because I feel > >>they are sending out letters like this just to scare us into >downcoding. > >>My best friend is the compliance officer for a nearby hospital > >>ambulatory care center, doing all of their auditing, and she also works > >>for a company that does just such audits nationwide. She has audited my > >>charting previously, at my request, and tells me I am doing things > >>appropriately. But I hate to " tick off " this company and their director > >>and forever have the spotlight on my practice. By the way, I do not >have > >>EHR; we use only paper charts with hand written notes. I have used the > >>StatCoder program on my PDA and find that, according to that, my coding > >>is appropriate, although some issues like medical decision making, can >be > > >>somewhat grey areas. > >> > >> > >>Any ideas would be appreciated. > >> > >> > >>Sue > >> > >> > >> > >> > >> > >>YAHOO! GROUPS LINKS > >> > >> Visit your group " " on the web. > >> > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 I generally agree with that on the established codes, but do still use an occasional 99212. How do you code a child that comes in with 3 days of runny nose & nothing else significant & really just wanted a school note as the " actual reason for coming " ? That is a 99212 unless you go searching for reasons to upcode the visit (excuse me, provide more complete care as others here call it). RE: " Overcoding > issues " > >> > >> > >>I don't see how we can ever expect a bell curve > out of a 5 point > scale > >>that really only has 2 " usable codes " . In my > simple minded way of > >>looking at things " (sticking to established > patients for this > discussion) > > >>99211 can't happen in my office, as I have no > nurse === message truncated === Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 I generally agree with that on the established codes, but do still use an occasional 99212. How do you code a child that comes in with 3 days of runny nose & nothing else significant & really just wanted a school note as the " actual reason for coming " ? That is a 99212 unless you go searching for reasons to upcode the visit (excuse me, provide more complete care as others here call it). RE: " Overcoding > issues " > >> > >> > >>I don't see how we can ever expect a bell curve > out of a 5 point > scale > >>that really only has 2 " usable codes " . In my > simple minded way of > >>looking at things " (sticking to established > patients for this > discussion) > > >>99211 can't happen in my office, as I have no > nurse === message truncated === Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 The PE also depends on whether you are using 1995 or 1997 criteria--for example-using body systems, - ear, nose, and throat actually only count as one, not 3 as in this example. Heart, Respiratory would be another 2. 3 vitals would be another, using one set of criteria (can't remember if its 95 or 97). If I recall correctly, you need 5-7 body systems for 99203 and 8 plus for 99204. But you can also use the other set of criteria, for instance if you do an extensive exam for one system only-for instance a neuro exam, with all of its individual components. I think you need 11 "bullets," if I remember correctly, which you could achieve with such an exam. Sue "Overcoding issues"> >>> >>> >>I have been following this group and have learned a lot. I appreciate >all>> >>of the advice! I have a question with which I would like some help.> >>> >>> >>I recently received a letter from one of our larger HMO's that said my> >>coding was above average for Family Medicine physicians, comparing >their> >>2004 data to my 2005-as it related to 99214-15's. They said that they >are>> >>going to monitor my billing and, if that trend continues, they will be> >>auditing my records.> >>> >>> >>My initial thoughts-I know that many of us previously downcoded to 13's> >>so as not to have to think or document, or to avoid just such letters. >I> >>also know that the "bell curve" is moving upward because we are now> >>becoming more proficient in coding, so the published data from even a >few>> >>years ago is not accurate now. I am just starting up (1.5 years in this> >>practice). I only have about 75 patients in my panel for this >particular> >>group, and, in this short time frame, it has been mainly the more >"sick"> >>patients that are coming in. I am getting many chronically ill patients> >>with numerous problems, from our other ambulatory sites (I am hospital> >>employed), and, although these pts. are new to me, I have to bill them >as>> >> established because all of the sites have the same Tax Id, and these> >>pts are all considered established. Needing to cover so many issues at> >>the "new" visit obviously results in many (mostly) 99214's.> >>Realistically, I feel that my panel is not large enough to have even> >>developed enough data for a "normal" bell curve, but I could be just> >>rationalizing all of this to support my data!> >>> >>> >>My question-should I be pro active and contact the medical director of> >>this HMO who sent the letter to discuss this, find out the time frame >for>> >>their previous monitoring, and do my own audit of my charting? And if >my> >>charting supports my billing pursue this to "prove" to them I am coding> >>appropriately (if my charts verify this)? Or should I not worry about >it,>> >>just be sure to focus particularly on this group to make sure I do >things>> >>appropriately in the future. I hate to just let this go because I feel> >>they are sending out letters like this just to scare us into >downcoding.> >>My best friend is the compliance officer for a nearby hospital> >>ambulatory care center, doing all of their auditing, and she also works> >>for a company that does just such audits nationwide. She has audited my> >>charting previously, at my request, and tells me I am doing things> >>appropriately. But I hate to "tick off" this company and their director> >>and forever have the spotlight on my practice. By the way, I do not >have> >>EHR; we use only paper charts with hand written notes. I have used the> >>StatCoder program on my PDA and find that, according to that, my coding> >>is appropriate, although some issues like medical decision making, can >be>> >>somewhat grey areas.> >>> >>> >>Any ideas would be appreciated.> >>> >>> >>Sue> >>> >>> >>> >>> >>> >>YAHOO! GROUPS LINKS> >>> >> Visit your group "" on the web.> >>> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 The PE also depends on whether you are using 1995 or 1997 criteria--for example-using body systems, - ear, nose, and throat actually only count as one, not 3 as in this example. Heart, Respiratory would be another 2. 3 vitals would be another, using one set of criteria (can't remember if its 95 or 97). If I recall correctly, you need 5-7 body systems for 99203 and 8 plus for 99204. But you can also use the other set of criteria, for instance if you do an extensive exam for one system only-for instance a neuro exam, with all of its individual components. I think you need 11 "bullets," if I remember correctly, which you could achieve with such an exam. Sue "Overcoding issues"> >>> >>> >>I have been following this group and have learned a lot. I appreciate >all>> >>of the advice! I have a question with which I would like some help.> >>> >>> >>I recently received a letter from one of our larger HMO's that said my> >>coding was above average for Family Medicine physicians, comparing >their> >>2004 data to my 2005-as it related to 99214-15's. They said that they >are>> >>going to monitor my billing and, if that trend continues, they will be> >>auditing my records.> >>> >>> >>My initial thoughts-I know that many of us previously downcoded to 13's> >>so as not to have to think or document, or to avoid just such letters. >I> >>also know that the "bell curve" is moving upward because we are now> >>becoming more proficient in coding, so the published data from even a >few>> >>years ago is not accurate now. I am just starting up (1.5 years in this> >>practice). I only have about 75 patients in my panel for this >particular> >>group, and, in this short time frame, it has been mainly the more >"sick"> >>patients that are coming in. I am getting many chronically ill patients> >>with numerous problems, from our other ambulatory sites (I am hospital> >>employed), and, although these pts. are new to me, I have to bill them >as>> >> established because all of the sites have the same Tax Id, and these> >>pts are all considered established. Needing to cover so many issues at> >>the "new" visit obviously results in many (mostly) 99214's.> >>Realistically, I feel that my panel is not large enough to have even> >>developed enough data for a "normal" bell curve, but I could be just> >>rationalizing all of this to support my data!> >>> >>> >>My question-should I be pro active and contact the medical director of> >>this HMO who sent the letter to discuss this, find out the time frame >for>> >>their previous monitoring, and do my own audit of my charting? And if >my> >>charting supports my billing pursue this to "prove" to them I am coding> >>appropriately (if my charts verify this)? Or should I not worry about >it,>> >>just be sure to focus particularly on this group to make sure I do >things>> >>appropriately in the future. I hate to just let this go because I feel> >>they are sending out letters like this just to scare us into >downcoding.> >>My best friend is the compliance officer for a nearby hospital> >>ambulatory care center, doing all of their auditing, and she also works> >>for a company that does just such audits nationwide. She has audited my> >>charting previously, at my request, and tells me I am doing things> >>appropriately. But I hate to "tick off" this company and their director> >>and forever have the spotlight on my practice. By the way, I do not >have> >>EHR; we use only paper charts with hand written notes. I have used the> >>StatCoder program on my PDA and find that, according to that, my coding> >>is appropriate, although some issues like medical decision making, can >be>> >>somewhat grey areas.> >>> >>> >>Any ideas would be appreciated.> >>> >>> >>Sue> >>> >>> >>> >>> >>> >>YAHOO! GROUPS LINKS> >>> >> Visit your group "" on the web.> >>> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Of course, in that FPM article regarding 99214's it says that a good rule of thumb is to think 99214 if you have a new problem that requires a prescription. That is getting carried away. I don't know if most have ever looked, but there are numerous clinical examples of correct E/M codes near the back of the official AMA CPT manual. People will probably be surprised with some of them. One example: initial visit for a pt needing refill of a topical steroid to treat lichen planus. Code recommended to assign? 99201. " Overcoding issues " > > >> > > >> > > >>I have been following this group and have learned a lot. I appreciate > >all > > > > >>of the advice! I have a question with which I would like some help. > > >> > > >> > > >>I recently received a letter from one of our larger HMO's that said >my > > >>coding was above average for Family Medicine physicians, comparing > >their > > >>2004 data to my 2005-as it related to 99214-15's. They said that they > >are > > > > >>going to monitor my billing and, if that trend continues, they will >be > > >>auditing my records. > > >> > > >> > > >>My initial thoughts-I know that many of us previously downcoded to >13's > > >>so as not to have to think or document, or to avoid just such >letters. > >I > > >>also know that the " bell curve " is moving upward because we are now > > >>becoming more proficient in coding, so the published data from even a > >few > > > > >>years ago is not accurate now. I am just starting up (1.5 years in >this > > >>practice). I only have about 75 patients in my panel for this > >particular > > >>group, and, in this short time frame, it has been mainly the more > > " sick " > > >>patients that are coming in. I am getting many chronically ill >patients > > >>with numerous problems, from our other ambulatory sites (I am >hospital > > >>employed), and, although these pts. are new to me, I have to bill >them > >as > > > > >> established because all of the sites have the same Tax Id, and >these > > >>pts are all considered established. Needing to cover so many issues >at > > >>the " new " visit obviously results in many (mostly) 99214's. > > >>Realistically, I feel that my panel is not large enough to have even > > >>developed enough data for a " normal " bell curve, but I could be just > > >>rationalizing all of this to support my data! > > >> > > >> > > >>My question-should I be pro active and contact the medical director >of > > >>this HMO who sent the letter to discuss this, find out the time frame > >for > > > > >>their previous monitoring, and do my own audit of my charting? And if > >my > > >>charting supports my billing pursue this to " prove " to them I am >coding > > >>appropriately (if my charts verify this)? Or should I not worry about > >it, > > > > >>just be sure to focus particularly on this group to make sure I do > >things > > > > >>appropriately in the future. I hate to just let this go because I >feel > > >>they are sending out letters like this just to scare us into > >downcoding. > > >>My best friend is the compliance officer for a nearby hospital > > >>ambulatory care center, doing all of their auditing, and she also >works > > >>for a company that does just such audits nationwide. She has audited >my > > >>charting previously, at my request, and tells me I am doing things > > >>appropriately. But I hate to " tick off " this company and their >director > > >>and forever have the spotlight on my practice. By the way, I do not > >have > > >>EHR; we use only paper charts with hand written notes. I have used >the > > >>StatCoder program on my PDA and find that, according to that, my >coding > > >>is appropriate, although some issues like medical decision making, >can > >be > > > > >>somewhat grey areas. > > >> > > >> > > >>Any ideas would be appreciated. > > >> > > >> > > >>Sue > > >> > > >> > > >> > > >> > > >> > > >>YAHOO! GROUPS LINKS > > >> > > >> Visit your group " " on the web. > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Of course, in that FPM article regarding 99214's it says that a good rule of thumb is to think 99214 if you have a new problem that requires a prescription. That is getting carried away. I don't know if most have ever looked, but there are numerous clinical examples of correct E/M codes near the back of the official AMA CPT manual. People will probably be surprised with some of them. One example: initial visit for a pt needing refill of a topical steroid to treat lichen planus. Code recommended to assign? 99201. " Overcoding issues " > > >> > > >> > > >>I have been following this group and have learned a lot. I appreciate > >all > > > > >>of the advice! I have a question with which I would like some help. > > >> > > >> > > >>I recently received a letter from one of our larger HMO's that said >my > > >>coding was above average for Family Medicine physicians, comparing > >their > > >>2004 data to my 2005-as it related to 99214-15's. They said that they > >are > > > > >>going to monitor my billing and, if that trend continues, they will >be > > >>auditing my records. > > >> > > >> > > >>My initial thoughts-I know that many of us previously downcoded to >13's > > >>so as not to have to think or document, or to avoid just such >letters. > >I > > >>also know that the " bell curve " is moving upward because we are now > > >>becoming more proficient in coding, so the published data from even a > >few > > > > >>years ago is not accurate now. I am just starting up (1.5 years in >this > > >>practice). I only have about 75 patients in my panel for this > >particular > > >>group, and, in this short time frame, it has been mainly the more > > " sick " > > >>patients that are coming in. I am getting many chronically ill >patients > > >>with numerous problems, from our other ambulatory sites (I am >hospital > > >>employed), and, although these pts. are new to me, I have to bill >them > >as > > > > >> established because all of the sites have the same Tax Id, and >these > > >>pts are all considered established. Needing to cover so many issues >at > > >>the " new " visit obviously results in many (mostly) 99214's. > > >>Realistically, I feel that my panel is not large enough to have even > > >>developed enough data for a " normal " bell curve, but I could be just > > >>rationalizing all of this to support my data! > > >> > > >> > > >>My question-should I be pro active and contact the medical director >of > > >>this HMO who sent the letter to discuss this, find out the time frame > >for > > > > >>their previous monitoring, and do my own audit of my charting? And if > >my > > >>charting supports my billing pursue this to " prove " to them I am >coding > > >>appropriately (if my charts verify this)? Or should I not worry about > >it, > > > > >>just be sure to focus particularly on this group to make sure I do > >things > > > > >>appropriately in the future. I hate to just let this go because I >feel > > >>they are sending out letters like this just to scare us into > >downcoding. > > >>My best friend is the compliance officer for a nearby hospital > > >>ambulatory care center, doing all of their auditing, and she also >works > > >>for a company that does just such audits nationwide. She has audited >my > > >>charting previously, at my request, and tells me I am doing things > > >>appropriately. But I hate to " tick off " this company and their >director > > >>and forever have the spotlight on my practice. By the way, I do not > >have > > >>EHR; we use only paper charts with hand written notes. I have used >the > > >>StatCoder program on my PDA and find that, according to that, my >coding > > >>is appropriate, although some issues like medical decision making, >can > >be > > > > >>somewhat grey areas. > > >> > > >> > > >>Any ideas would be appreciated. > > >> > > >> > > >>Sue > > >> > > >> > > >> > > >> > > >> > > >>YAHOO! GROUPS LINKS > > >> > > >> Visit your group " " on the web. > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 > >Then give me an example of what would constitute a 99201 and a 99202. >There >are 5 levels for a reason. > I've never coded a level 1 or 2 visit for a new patient. I have done level 2 visits for established patients if they are coming in for just a flu shot or allergy shot. HPI is very brief - feeling well today, no hx of rxn to previous shots, etc. Exam is minimal - vitals signs, general assessment that pt looks well, heart, lungs. I have never done a level 1 visit, even for established pts, so I'm not claiming to know this for sure - but I believe that the only appropriate time to use them is if the pt saw someone besides the doctor and the doctor just had to review - such as bp check, ua, etc. Just because they are there, doesn't mean you need to use them if they don't accurately reflect the care you've provided. Any other opinions on this??? Debbie New Jersey > > " Overcoding issues " > > >> > > >> > > >>I have been following this group and have learned a lot. I appreciate > >all > > > > >>of the advice! I have a question with which I would like some help. > > >> > > >> > > >>I recently received a letter from one of our larger HMO's that said >my > > >>coding was above average for Family Medicine physicians, comparing > >their > > >>2004 data to my 2005-as it related to 99214-15's. They said that they > >are > > > > >>going to monitor my billing and, if that trend continues, they will >be > > >>auditing my records. > > >> > > >> > > >>My initial thoughts-I know that many of us previously downcoded to >13's > > >>so as not to have to think or document, or to avoid just such >letters. > >I > > >>also know that the " bell curve " is moving upward because we are now > > >>becoming more proficient in coding, so the published data from even a > >few > > > > >>years ago is not accurate now. I am just starting up (1.5 years in >this > > >>practice). I only have about 75 patients in my panel for this > >particular > > >>group, and, in this short time frame, it has been mainly the more > > " sick " > > >>patients that are coming in. I am getting many chronically ill >patients > > >>with numerous problems, from our other ambulatory sites (I am >hospital > > >>employed), and, although these pts. are new to me, I have to bill >them > >as > > > > >> established because all of the sites have the same Tax Id, and >these > > >>pts are all considered established. Needing to cover so many issues >at > > >>the " new " visit obviously results in many (mostly) 99214's. > > >>Realistically, I feel that my panel is not large enough to have even > > >>developed enough data for a " normal " bell curve, but I could be just > > >>rationalizing all of this to support my data! > > >> > > >> > > >>My question-should I be pro active and contact the medical director >of > > >>this HMO who sent the letter to discuss this, find out the time frame > >for > > > > >>their previous monitoring, and do my own audit of my charting? And if > >my > > >>charting supports my billing pursue this to " prove " to them I am >coding > > >>appropriately (if my charts verify this)? Or should I not worry about > >it, > > > > >>just be sure to focus particularly on this group to make sure I do > >things > > > > >>appropriately in the future. I hate to just let this go because I >feel > > >>they are sending out letters like this just to scare us into > >downcoding. > > >>My best friend is the compliance officer for a nearby hospital > > >>ambulatory care center, doing all of their auditing, and she also >works > > >>for a company that does just such audits nationwide. She has audited >my > > >>charting previously, at my request, and tells me I am doing things > > >>appropriately. But I hate to " tick off " this company and their >director > > >>and forever have the spotlight on my practice. By the way, I do not > >have > > >>EHR; we use only paper charts with hand written notes. I have used >the > > >>StatCoder program on my PDA and find that, according to that, my >coding > > >>is appropriate, although some issues like medical decision making, >can > >be > > > > >>somewhat grey areas. > > >> > > >> > > >>Any ideas would be appreciated. > > >> > > >> > > >>Sue > > >> > > >> > > >> > > >> > > >> > > >>YAHOO! GROUPS LINKS > > >> > > >> Visit your group " " on the web. > > >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 My points exactly. My comments were to emphasize the benefit of switching from one set of criteria to the other (95 or 97) depending the situation. Because the exam is often the limiting factor, being able to count elements (bullets) individually will often benefit us in determining the E and M level. I alternate between both sets of guidelines depending on the situation. Sue "Overcoding issues"> > >>> > >>> > >>I have been following this group and have learned a lot. I >appreciate> >all> >> > >>of the advice! I have a question with which I would like some help.> > >>> > >>> > >>I recently received a letter from one of our larger HMO's that said >my> > >>coding was above average for Family Medicine physicians, comparing> >their> > >>2004 data to my 2005-as it related to 99214-15's. They said that >they> >are> >> > >>going to monitor my billing and, if that trend continues, they will >be> > >>auditing my records.> > >>> > >>> > >>My initial thoughts-I know that many of us previously downcoded to >13's> > >>so as not to have to think or document, or to avoid just such >letters.> >I> > >>also know that the "bell curve" is moving upward because we are now> > >>becoming more proficient in coding, so the published data from even >a> >few> >> > >>years ago is not accurate now. I am just starting up (1.5 years in >this> > >>practice). I only have about 75 patients in my panel for this> >particular> > >>group, and, in this short time frame, it has been mainly the more> >"sick"> > >>patients that are coming in. I am getting many chronically ill >patients> > >>with numerous problems, from our other ambulatory sites (I am >hospital> > >>employed), and, although these pts. are new to me, I have to bill >them> >as> >> > >> established because all of the sites have the same Tax Id, and >these> > >>pts are all considered established. Needing to cover so many issues >at> > >>the "new" visit obviously results in many (mostly) 99214's.> > >>Realistically, I feel that my panel is not large enough to have >even> > >>developed enough data for a "normal" bell curve, but I could be >just> > >>rationalizing all of this to support my data!> > >>> > >>> > >>My question-should I be pro active and contact the medical director >of> > >>this HMO who sent the letter to discuss this, find out the time >frame> >for> >> > >>their previous monitoring, and do my own audit of my charting? And >if> >my> > >>charting supports my billing pursue this to "prove" to them I am >coding> > >>appropriately (if my charts verify this)? Or should I not worry >about> >it,> >> > >>just be sure to focus particularly on this group to make sure I do> >things> >> > >>appropriately in the future. I hate to just let this go because I >feel> > >>they are sending out letters like this just to scare us into> >downcoding.> > >>My best friend is the compliance officer for a nearby hospital> > >>ambulatory care center, doing all of their auditing, and she also >works> > >>for a company that does just such audits nationwide. She has >audited my> > >>charting previously, at my request, and tells me I am doing things> > >>appropriately. But I hate to "tick off" this company and their >director> > >>and forever have the spotlight on my practice. By the way, I do not> >have> > >>EHR; we use only paper charts with hand written notes. I have used >the> > >>StatCoder program on my PDA and find that, according to that, my >coding> > >>is appropriate, although some issues like medical decision making, >can> >be> >> > >>somewhat grey areas.> > >>> > >>> > >>Any ideas would be appreciated.> > >>> > >>> > >>Sue> > >>> > >>> > >>> > >>> > >>> > >>YAHOO! GROUPS LINKS> > >>> > >> Visit your group "" on the web.> > >>> > >> Quote Link to comment Share on other sites More sharing options...
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