RE: 'Overcoding issues'

January 31, 2006

--

My first impression was the same -- that your description seemed at least

to fit 99203. The trick is to have enough for all three components. It's

easy to trip up on ROS as I believe you need >3, but you seemed to have it

covered. One thought is to sign/date the sheet the patient filled out or

make explicit reference to it in the note as having been reviewed. The

physical exam is another area many might miss. Always try to make a few

comments about each part of the body... " ears benign " may not get credit,

it's better to refer to outer ear/canals/TM's separately... also something

like lymph nodes, to get credit you have to make reference to at least two

areas of nodes (I check bilat anterior cerv and supraclavicular areas

myself).

Also, get all the details about any kind of pain as that may not get

credit in an audit if not fully described (location, severity,

description, radiation, timing, etc...)

Tim

> :

>

> You are not overcoding, but you may be undercoding! How you've

> described it, your visits would definitely meet 99203, and some

> probably meet 99204. Family Practice Management regularly reprints the

> table that describes required documentation for patient visits. You

> can probably print-out from website at www.aafp.org/fpm - from that

> table:

>

> 99203 - all 3 components required (Hx, exam and decision making)

>

> hx: cc, 1-3 elements of HPI, pertinent ROS

>

> exam: 6-11 elements (in general, each body part is an element, although

> sometimes 1 body part can be >1 element if detailed exam of that one

> body part) For example: ears, nose, oropharynx, heart, lungs, abd is 6

> elements (at least)

>

> decision making: low

>

> Debbie J.

> New Jersey

>

>>

>>Reply-To:

>>To:

>>Subject: Re: " Overcoding issues "

>>Date: Mon, 30 Jan 2006 21:30:22 -0700

>>

>>I don't think I've ever coded a new visit less than 99203 - now I need

>> to go back and look again at the criteria. If they come in and

>> establish - I will have a full past medical/social history. The

>> intake sheet has a full ROS, I make sure and do a complete PE, even

>> if it's a sore throat -- but now I'm worried I am overcoding them.

>> Can I get some opinions on what fulfills a 99203?

>>

>>>I see what you are saying with the established codes. Yes, the vast

>>> majority are either 99213 or 99214. Still I do have a few each of

>>> 99212 & 99215, so it will at least be a distribution if not a true

>>> “bell”. But in regards to the new visit codes, I definitely use the

>>> full bell. I only rarely use a 99205 but routinely use 99201,

>>> 99202, 99203, 99204. Basically, I think most doctors still

>>> undercode established visits & overcode new visits. By the way, I

>>> agree completely about your interpretation of the 99215 code. It is

>>> not meant to be used for a visit that you spent an hour on

>>> counseling or for multiple stable problems (that would be the

>>> extended visit codes, etc).

>>>

>>> " 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.

>>>

January 31, 2006

Unless you and the pt. have decided on doing a complete PE, in which case it would be one of the preventive codes, you can't use that whole exam for "credit" in seeing a new pt. with a sore throat, or such. All of these criteria (therefore the exam, too) have to be "medically necessary." I full agree with you, and often do, much more than just examine the throat, respiratory, etc. for a new patient, just to get to know them, etc. But you can't use all of that info, if they are truly just in for a sore throat. The rest of the exam (like neuro, skeletal, etc.) is not really medically necessary, so you cannot count it. It is often the exam criteria that are limiting for coding new pts. because all 3 areas (ROS, HPI etc, Exam, and Decision Making) all must agree, to use the code, while with established, only 2 out of 3 are necessary.

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.>>>>>>

January 31, 2006

Rarely do I have a patient who truly comes

in for only one issue. There is generally something else……”Oh

yeah.. a few years ago I was told I had high Cholesterol” Often patients

talk about other issues that no MD has ever asked about. They feel safe

mentioning some things that have been bothering them but they didn’t want

to appear silly. Two weeks ago I had a 31yo male start quietly crying, no one

had been listening for 2 years. It was heartbreaking.

T.

Ellsworth, MD

Family Medicine

sdale, AZ

Mobile

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From:

[mailto: ] On

Behalf Of Sue Bidigare MD

Sent: Tuesday, January 31, 2006

4:54 AM

To:

Subject: Re:

'Overcoding issues'

Unless you and the pt. have decided on doing a complete PE,

in which case it would be one of the preventive codes, you can't use that whole

exam for " credit " in seeing a new pt. with a sore throat, or such.

All of these criteria (therefore the exam, too) have to be " medically

necessary. " I full agree with you, and often do, much more than just

examine the throat, respiratory, etc. for a new patient, just to get to know

them, etc. But you can't use all of that info, if they are truly just in for a

sore throat. The rest of the exam (like neuro, skeletal, etc.) is not really

medically necessary, so you cannot count it. It is often the exam criteria that

are limiting for coding new pts. because all 3 areas (ROS, HPI etc, Exam, and

Decision Making) all must agree, to use the code, while with established, only

2 out of 3 are necessary.

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.

>>>

January 31, 2006

Exactly! I’ve said that here many

times but few seemed to agree with me. Just because you documented something does

not mean it was medically necessary, and unfortunately insurance companies

still use that as the overarching determinant of which code is proper.

Re:

'Overcoding issues'

Unless you and the pt. have decided

on doing a complete PE, in which case it would be one of the preventive codes,

you can't use that whole exam for " credit " in seeing a new pt. with a

sore throat, or such. All of these criteria (therefore the exam, too) have to

be " medically necessary. " I full agree with you, and often do, much

more than just examine the throat, respiratory, etc. for a new patient, just to

get to know them, etc. But you can't use all of that info, if they are truly

just in for a sore throat. The rest of the exam (like neuro, skeletal, etc.) is

not really medically necessary, so you cannot count it. It is often the exam

criteria that are limiting for coding new pts. because all 3 areas (ROS, HPI

etc, Exam, and Decision Making) all must agree, to use the code, while with

established, only 2 out of 3 are necessary.

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.

>>>

January 31, 2006

Yes but same answer: a new visit E/M

requires all 3 components. A complete exam & higher level decision

making would still may not be justified.