The lovely 99205, Only for Trainwrecks!

Today I want to cover the 99205......but first I think it is appropriate to give you the clinical case prior to boring you with the detail.....That way we can go blow by blow through the case and pick it apart.

The Scenario: 

You see a 65 year old man for the first time who is complaining of a 20 pound weight loss, dysphagia, and abdominal pain. His past medical history includes DM2, CAD, OA, Chronic Bronchitis, HTN, GERD and Hyperlipidemia. He takes 8 medications and hasn't seen a doctor in 19 months.

Like I said, 99205 is ONLY for the trainwrecks. There is no way you could even think about upcoding to a 99205. No Way!

I repeat   The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk

So let's go through the things that make this different from a 99204 first.

Medical Decision Making (MDM) of High Complexity, that's all. Nothing Else....

But boy, what a bar you are going to have to meet on this one.

What does high complexity MDM entail?

1. Number of Diagnoses or Management Options must be "Extensive"

2. Amount/Complexity of Data Reviewed must also be "Extensive"

3. Lastly, the Risk of MandM must be high....

We have reviewed these a little before, but let's recap.

Remember how I said MDM is difficult and is judged by 3 variable?

These Are Also Called:

A. Problem Points-In this case you need 4 points

B. Data Points-For the 99205 you also need 4 points

C. Risk-This has to be HIGH RISK,

High risk essentially means a condition that is placing the patient in IMMINENT threat of their life. I think you know what these are....but for the non-physicians out there let me give you a hint

1. Myocardial Infarction, but not stable Angina

2. Renal Failure, but not Renal Insufficiency

3. Trauma

4. TIA or Stroke

5. Pulmonary Embolism

6. Status Asthmaticus but not mild exacerbation

I think you get where I am going here......

99205 is only for Trainwrecks....I repeat only for Trainwrecks.......

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OIG's work plan.

Have you ever wondered what Medicare was going to focus on and who medicare was going to focus on with their Auditing of Charts? Well know you can. Bookmark this site. This is the work plan for the office of Inspector General of the United States.

From the Site:

The OlG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging. Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary. Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

Here's the plan

• Place of Service Errors
  
• Evaluation and Management Services During Global Surgery Periods
  
• Medicare Practice Expenses Incurred by Selected Physician Specialties
  
• Services Performed by Clinical Social Workers
  
• Outpatient Physical Therapy Services Provided by Independent Therapists
• Medicare Payments for Colonoscopy Services
  
• Physicians’ Medicare Services Performed by Nonphysicians
  
• Appropriateness of Medicare Payments for Polysomnography
  
• Long-Distance Physician Claims Requiring a Face-to-Face Visit
• Geographic Areas With a High Density of Independent Diagnostic Testing Facilities
  
• Patterns Related to High Utilization of Ultrasound Services
• Medicare Payments for Chiropractic Services Billed With the Acute Treatment Modifier
  
• Physician Reassignment of Benefits
  
• Medicare Payments for Unlisted Procedure Codes
  
• Laboratory Test Unbundling by Clinical Laboratories
  
• Variation of Laboratory Pricing
  
• Clotting Factor Furnishing Fee
  
• Medicare Billings With Modifier GY
  

If you are doing any of these things or have any issues with this. Consider this blog post fair warning!