Inpatient Admissions, 99222 and 99223

Do you really think caring for a patient in the hospital costs less than a patient out of the hospital? Apparently Insurance does.

It is the main reason why a decent amount of internal medicine doctors have relinquished their hospital care to doctors who are permanently in the hospital.....

Why should you get paid more for a complete physical with new problems than a patient who is septic and tachycardic?

Does it make any sense?

No.

Which is why I want to make sure you get paid what you should for your hospital care. I am going to cover 2 codes today.

If you have read my previous posts you will understand my philosophy.

1. Doctors often undercode for fear of audits, not because they did less work than they claim.
2. Doctor often think they are documenting properly, but are often wrong.
3. Thus doctors get audited and lose money for their services and the cycle perpetuates....

So with that in mind, let's take a systematic look at the hospital admission The codes 99222 and 99223 are what I will cover, because 99221 should probably not be admitted to the hospital.

Unless of course you have failed outpatient management with them.

99222 requires:
1. A Comprehensive History (See Here)
2. A Comprehensive Examination (See Here)
3. Medical Decision Making of Moderate Complexity

99223 requires:
Same as 99222 except this one key distinction.
Medical Decision Making of High Complexity......

What is the difference between Moderate and High? Not much really.
Try 1 Problem Point and 1 Data Point.

Huh? Ok, I guess if you said huh, you haven't read my other posts......

Medical Decision Making is Judged by 3 things. You need 2 of the 3 at the highest level you code for......

The things?
A. Problem Points. For each of the following things you document you receive points as below

New Problem with work up (4)

New problem no Work up (3)

Est Problem, Worsening (2)

Est Problem Stable(1)


What is the difference between Moderate and Complex? ONE point in this category plus ONE other point in Data, or classified as highest risk!


B. Data Points. For each of the following you document you also get points as below.


Labs Ordered OR Reviewed (1)

Indep Review of EKG/Film/Specimen (2)

Reviewed Old records (2)

Decision to Obtain Old Records(1)

Discuss test with Physician(1)

Order Test EKG/Cath/PFTs (1)


So in this case you need FOUR points to document High Risk, whereas you need 3 points for moderate.

The last item is titled Risk.

Risk is a nebulous little bugger which has been encapsulated in a table by EM University.

Personally I think it may be a little more complex than that, but the table is here for your viewing pleasure.

To meet the Risk criteria for a 99223 (The highest admission code) you need
High Risk

1. One or more chronic illness, with severe exacerbation or progression
2. Acute or chronic illness or injury, which poses a threat to life or bodily function
3. An abrupt change in neurological status
Or if you chose to do
1. Cardiovascular imaging, with contrast
2. Cardiac EP studies
3. Diagnostic endoscopies
4. Discography
5. Elective major surgery
6. Emergency major surgery
7. Parenteral controlled substances
8. Drug therapy requiring intensive monitoring for toxicity (Digoxin/Heparin)
9. Decision not to resuscitate, or to de-escalate care because of poor prognosis

I am certain there are more criteria than this, but I think you get my drift.
Most people you admit have one of 4 things.

1. Infection
2. Exacerbation of Chronic Disease
3. Chest Pain
4. Need Surgery

If you can claim that these conditions are severe, you can claim highest risk......
Or all you have to claim 4 points in Problems and 4 Points in Data.

Most doctors look at EKGs, Most doctors don't say independent review of EKG by me.... There is a huge difference to the insurers. The same is true for radiology studies......If you look at one film and look at one EKG, you have FOUR data points!!!!

That is enough to code at the highest level when you add 4 Problem points, which are probably the easiest to get. Now all you have to do is a comprehensive history and examination, which you better do when admitting a patient!

So In conclusion, most of your admissions will fall as 99223. Just look, take the time to document and get paid what you deserve!

99215 is closer than you think!

Once again there is an advantage to having established patients. Often the care for them is easier, you are working on their chronic diseases, preventing others from springing up, and you have great rapport......That does not mean that what you are providing is to be diminished......

What you provide, you should get paid for. Plain and simple. The coding system is a higher level order of communication which also happens to double as legal proof of what we do.........

So without further ado, I present to you that we should be coding more 99215 unlike the 99205, which are reserved for train wrecks dying in your office.

What does a 99215 require. I think we have been through what the majority of E and M codes look for. 3 parts History, Examination AND Medical Decision Making. In this case it requires

1. Comprehensive History
2. Comprehensive Examination
3. Medical Decision Making of High Complexity

Most people look at that and say, wow "High Complexity" I'm not so sure my patient with 5 diseases which I control rather well is complex........I say, "Give yourself some credit!"

Most importantly, with your established patient visits, you only need 2 out of 3 to make the grade for 99215 .......

Let's look at what a 99215 looks like clinically.

CHF exacerbation in a 60 year old man with diabetes and CHF with an EF of 35%. He notes increased SOB/DOE and leg swelling.

Another?

How about a 58 year old male with COPD and DM2 who presents with change in cough and increased medication utilization. He also notes a new fever.

As you can see, these are not TOO COMPLICATED as in not like an ICU patient on a ventilator, but these are sick patients......

99215 is for your sick but not dying patients......The ones you might end up admitting to the hospital, but often show up in the office on Friday afternoon.

Let's look at the cases and the requirements.

1. Comprehensive History.
There are 4 levels of History. Usually we end up doing detailed or comprehensive. This requires

A. 4 elements from History of Present Illness (think PQRI) Or 3 chronic stable problems!
B. 10 point ROS, a given with “All other systems reviewed and are negative.”
C. Plus a complete Past Family/Medical/Social History, which if there is no change you can document "No change since last reviewed fully on Date X". On your initial you need

That is It. That is all that you need for a Comprehensive history...

Oh, the elements for HPI. Didn't I go over those before? Fine! FYE (Edification)

1. Location
2. Quality
3. Severity
4. Duration
5. Timing
6. Context
7. Modifying Factors
8. Associated Signs and Symptoms

And the PFSH? Remember, it only takes ONE element from EACH component of PFSH to qualify for a complete PFSH. Do what is clinically needed. This is an easy one to get.

Next up.
2. Complete Physical Examination. This requires: 2 bullets from Nine of the 14 organ systems. You get one point for VS and One point for General Exam-This is called the constitutional system.......

You then need 2 items in 8 other systems. Here are the systems.
The 1997 E/M guidelines recognize the following organ systems:

• Constitutional
• Eyes
• Ears, nose, mouth and throat
• Neck
• Respiratory
• Cardiovascular
• Chest (breasts)
• Gastrointestinal (abdomen)
• Genitourinary (male)
• Genitourinary (female)
• Lymphatic
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric

14 Systems. You can't count Male and Female genitalia on MOST patients......

So if you do just these 2, then you qualify for a 99215. I should stop here.....
But I won't. The last of the 3 categories is the Medical Decision Making.

3. Medical decision making
Also judged by 3 categories. You only need 2 of the 3 at the highest level to meet the standards......

Those 3 categories are

Problem Points-4 points are Needed
Data Points-4 points are Needed
Medical Risk-High Risk is Needed

Remember, you only need 2 of 3 here.

How does it tally?

Problem Points

• New Problem with work up-4 points
• New Problem with NO work up-3 points
• Established Problem, worsening-2 points
• Established Problem, Stable-1 point

Data Points

• Independent Review of EKG/Film/Specimen-2 Points
• Review of Old Records-2 Points
  
• Labs/EKG/Film/PFTs Ordered/Reviewed-1 Point
• Discussion with Physician regarding test-1 Point

Medical Risk
Check the table or Just hit one of these

• One or more chronic illness, with severe exacerbation or progression
• Acute or chronic illness or injury, which poses a threat to life or bodily function (Tough)
• Cardiovascular imaging, EGD, or EP studies?
• Elective Major Surgery or Emergent Major Surgery
• Drug therapy requiring intensive monitoring for toxicity i.e. Heparin
• Decision to make DNR

Remember you only need 2 of the 3 here too.....Which means you likely will hit Data Points and Problem points more often than Risk points.....

So what I am saying is, if you have a patient with 3 chronic problems or if you have a patient with some new problems which make the patient sick, then you likely have a 99215. Internists used the 99215 to bill for only 4.1% of established office patients in 2003. Which IMHO is too low.

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99214, where we often are.

I am back and kicking! I want to continue our series of coding established patient office visits. Today's topic is the 99214. What I want everyone to appreciate about higher level coding your established patients is that there is a subtle distinction between them and your new patients.....

To code a level 4 99204 for your new patients, you are required to meet a higher standard than that of your established patients.....

In fact, you are required with new patients to meet ALL THREE criteria used to judge your notes. Whereas in an established patient you are only required to meet TWO of the THREE criteria. This is huge when it comes to collecting what you deserve for what you perform.........

This is what it looks like: 48 year old man who comes in for a follow up of his HTN and Hyperlipids and Rheumatoid Arthritis.....all are stable.
Another?
A 38 year old man who comes in with an acute problem and a stable problem....that should cut it as well.....It could be a woman too.....doesn't matter.
In the 99214 you are require to meet 2 of the following 3 criteria
1. A detailed history
2. A detailed examination
3. Medical Decision Making of Moderate Complexity......

Which means, patients with relatively simple conditions that require you to take detailed histories and exams on ARE IN FACT 99214 codes! Unlike as if they were a new patient.... So let's go to how this is judged and review it once again.....

You can look at my post about the 99204 for how new patient visit is judged.....But that level is a little higher than the 99214...... Or maybe we should be more clear the 99214 requires FAR LESS than the 99204....
Huh?
Yes, correct, a 99214 is a lower code than a 99204.....which is why insurance pays less for it.
Not because it is an established patient, but because it is LESS SERVICE!!! FAR LESS SERVICE.
A level 4 established patient is NOT a level 4 new patient.......get the fact that a Level 4 is a Level 4 out of your heads now!!!!

So let's review
1. Detailed History:

Let's examine what the definition of "Detailed" is.

"Detailed History"-Requires a Chief Complaint (CC), "extended" HPI, problem pertinent Review of Systems (ROS) which is "extended" to include a limited review of:

A. Family History

B. Social History

C. Past Medical History

All directly related to patient's problem.....requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems, plus TWO to NINE ROS, plus at least ONE pertinent element of PFSH .

Do you remember the HPI Elements? What about the 10 Systems for Review or the PFSHx? If yes, then congratulations. If no, then let's begin.

HPI Elements are:

1. Location
2. Quality
3. Severity
4. Duration
5. Timing
6. Context
7. Modifying Factors
8. Associated Signs and Symptoms

There are 2 levels of HPI-Brief and Extended....Most often you are doing an Extended HPI. You essentially have to document 4 of the preceding categories....for ONE problem.

It is as simple as this from EM University: Patient complains of chest pain (location), which began three hours ago (duration). Pain has been off and on since that time with each episode lasting two to three minutes (timing). The pain is described as “crushing” (quality) and at times is rated as an eight on a scale of one to ten (severity). The pain occurs with minimal exertion (context) and is associated with nausea and shortness of breath (associated signs and symptoms). The pain was relieved with sublingual NTG in the ambulance (modifying factors).

This is all you need to do to qualify for Extended HPI, which is wy more often than not, you are doing an extended HPI.

The Review of Systems? Do you remember which they are? In this case we need 2-9 systems, not even the 10 systems......Who does that? Maybe with a hyperacute issue. Which is why you would be billing a level 2-3 for that. The systems, all 14 of them There are fourteen individual systems recognized by the E/M guidelines:

1. Constitutional (e.g., fever, weight loss)
2. Eyes
3. Ears, Nose, Mouth, Throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic
    

There are 3 levels of the ROS
In the case of 99214 you need 2 to 9 systems it is called an "Extended ROS". Whereas the highest ROS is called a Complete ROS.
Why wouldn't you do a complete ROS every time?
Maybe you are pressured to see 20 patients a day and can't provide the highest level of care......
Even better, the staff can do the ROS for you.....Remember that!
Lastly, to meet detailed HPI you have to document one element of pertinent Family/Social/Medical History.
If nothing has changed, you can document no changes since the LAST TIME YOU DOCUMENTED A FULL ROS..........legally that is valid thing to do.
As for PFSH.....do I really have to do this again? You should have been reading the other posts!

There are 2 levels of PFSH, Pertinent and Complete. Pertinent PFSH requires at least ONE in one of the 3 categories-Past Medical, Past Social or Family History. Allergies and Medications are part of Past Medical.
2 key points here. 1. A staff member may take the PFSH, thus freeing you up.
2. You ONLY require one medical, one social and one family item to qualify for a "Complete" PFSH, which is probably what you are doing anyways.....

In the 99214 you need a Detailed History, which once again is: The second highest level of history and requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems plus TWO to NINE ROS, plus at least ONE pertinent element of PFSH .

I think you get my drift.....Your detailed history is ALMOST ALWAYS PERFORMED......Which is why you may be missing your 99214s.

In 2003 Internists used this code only 1/4 of all visits....My guess is that they are actually about half of all visits!

Now onto.....
2. Detailed Examination.

Remember the 1997 rules for examination. Bullets and Systems....that's how it goes...... It is 12 Bullets (Things examined) in ANY ORGAN SYSTEM.....One Bullet for Vitals, One for General Appearance and it is now only 10 bullets in any of the 14 systems. I am not going into those systems. But once again, if you do this and the history, then you are done and you have hit a 99214.......

Lastly, you can get there by one of those 2 and the medical decision making. The 99214 requires Medical Decision Making of Moderate Complexity, just like the 99204.

Which is probably why you confused the level 4 new visit as the same service as the level 4 established visit.....

Which, we now all know, it is not.

Moderate Complexity once again is divided into 3 parts
A. Problem Points
B. Data Points
C. Medical Risk (morbidity and mortality) Remember you need only 2 out of 3 of these targets to meet moderate complexity.

Problem Points-You need 3 points

• New Problem with work up-4 points
• New Problem with NO work up-3 points
• Established Problem, worsening-2 points
• Established Problem, Stable-1 point

Data Points

• Independent Review of EKG/Film/Specimen-2 Points
• Review of Old Records-2 Points
  
• Labs/EKG/Film/PFTs Ordered/Reviewed-1 Point
• Discussion with Physician regarding test-1 Point

Risk?

• 2 or more stable chronic illnesses-Bingo
• 1 Chronic Illness with mild exacerbation-Bingo
• 1 New undiagnosed problem-You have it
• 1 Complicated Injury-Again, you hit the risk....

How do we define the risk? With a risk table of course......

There you have it! Have you been missing your 99214 codes? I bet you have. 99214 is about 50% of what we are doing! Remember that.

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99213 yipee!!! Level 3 established visits.

According to EM university, in 2003 this code was used 56.7 percent of the time for internal medicine coding. It is no surprise that we like this "middle of the road" code. The problem is, just because we think it is middle of the road, doesn't make it so. In fact, I would say that the 99213 is so remarkably similar to the 99214 that you may be surprised how very many 99214s you are missing by picking the road most traveled.

Let's take a look at the anatomy of the 99213..

The 99213 is a visit with an established patient that you have seen in the LAST 3 YEARS......which requires a certain level of work and documentation. These requirements are:

1. An "Expanded" Problem focused History
2. An "Expanded" Problem Focused Examination
3. Medial Decision Making of Low Complexity

As you can see, this is made to look like the 99212 except "Expanded" which is why people think it is, to quote Goldilocks......"Just Right"

I beg to differ. In fact I think once you have the needed elements for a 99213 you may be surprisingly close to a 99214.

It all comes down to the documentation.

Lets look at each Element

• The "Expanded" Problem Focused History

What the hell does that mean????

This history requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.

Are you telling me that you don't do a review of Past Family, Medical or Social History with each patient? Isn't that what they want us to do with medicine reconciliation??

So likely you will exceed this requirement. An ROS of ONE system? Why do just one? I can think of a million reasons why even simple complaints need more than this.

• An "Expanded" Problem Focused Examination

Do you remember bullets? Not dodging them.....hitting them. In the 1997 physical exam rules a bullet system divided organ systems up into the sub exams...i.e. Conjunctivae, Sclera, Fundus for the eye.....

In the "Expanded" Problem Focused Examination you need, 6 bullets from ONE or more organ system......
Vitals signs? 1 Bullet
General Appearance? 1 Bullet

So all you need to do after this is examine 4 other "things" in the same or other organ systems.
Don't remember bullets? You can read about them by clicking here.

The problem is that to reach the next level, you need a much more comprehensive exam. But, the big kicker is that with established patients 99212, 99213, 99214, 99215 you only need 2 out of 3 categories to bill at the highest level. So you may qualify for a 99214 without doing that thorough an examination......Don't let your "Gut" tell you what to code.

The third category as always is the Medical Decision Making........otherwise known as the MDM

In this case, for the 99213 you need low complexity medical decision making......this is what bugs me.........just because your patient is "middle of the road" doesn't mean his MDM is.....

Which is the point that is being made here by the AMA. Is "Low Complexity Medical Decision Making" middle of the road for what you do? Probably not. Diabetes? Not really low complexity. Hypertension, a lot of the time this is not low level either. I view low level like the AMA views low level...In essence, the patient could come in with just ONE chronic problem, Which is STABLE and you make the MDM case. We start with the Points........Yes, MDM is divided up in 3 parts

1. Problem Points-In this case, you need 2 problem points? Do you remember the points per problem? You can review them here.

2. Data Points-These points are for data you review or order. In the 99213 you need 2 of them as well. You can review them here.

3. Risk-I really love this one. Low risk is "Only Marginally Higher than Marginal Risk" WTF? Ok, so just about everything outside of bug bite qualifies as at LEAST Low Risk. Which means, you probably are undercoding if you select 99213....

You should always ask yourself as you put 99213 down on the superbill........Is it really JUST a 99213? Chances are, you would be incorrect and it is in fact a 99214. Remember, just hitting MDM and History gets you a 99214 instead of all 3 being required in the New Patient 99204.

Want to see a 99213?

Here we go,

A 56 year old man present for follow up of well controlled hypertension wishing to change medications. He has absolutely no other complaints......

Anything above and beyond and you should start thinking about a 99214.

Did I just blow your mind? It did mine the first time I saw this.......

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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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RACs and RUCs and 99204s, Oh My!!!

Today is the next installment in the New Patient Office Visit Series.

We will be covering the 99204 CPT code. In 2003 it was selected 30% of the time for the new patient encounter.....which means just about 65% of patients fit into the 99203 or 99204 zone. My guess is that by the time we are done, you will be using 99204 much more than not.

So what is a 99204?

99204 requires these 3 components

1. A "Comprehensive" History

2. A "Comprehensive" Examination

3. Medical Decision Making of "Moderate" Complexity

Once again the definition of Moderate and Comprehensive are key here.

Moderate Complexity Decision Making is often audited and requires:

A. Multiple Diagnoses or Management Options. AMA doesn't list the exact number here but E and M University has a good wrap up 

The take home is that new problems with additional work up gets a maximum of 4 problem points. If it is a new problem with no further work up it is 3 points.

You can feel pretty confident  billing 99204 here if you have 3 points here AND

B. Amount and/or complexity of data reviewed has to be moderate as well. 

In this case you would need 3 data points reviewed. Ordering clinical lab tests counts as 1 point. So does ordering a radiology test, the same with EKG.

Discussing the results with a physician gives you a measly one point as well. But independent review of the specimen, image or tracing gives you 2 points......

So if you looked at the film, document that you looked at the film....or EKG.....

Review and summation of Old Records ALSO gives you 2 points.......

You can consider yourself getting warm here if you have 3 data points here AND 3 problem points.......

C. Moderate Risk of Complications, Morbidity or Mortality.....Well, what does that mean?

You can turn to the "Table of Risk!"

This basically indicates that you have one thing of 3 categories......

Category A-Presenting Problems

One or more chronic illnesses with mild exacerbation

Two or more stable chronic illnesses (HTN and Hyperlipidemia)

One Undiagnosed New problem

Acute Illness with Systemic Symptoms

Category B-Diagnostic Procedures

Stress Test or Fetal Stress test

Diagnostic Endoscopies

Deep Needle or Incisional Biopsies

Cardiac Cath

Fluid removal from Body Cavity

Category C-Management Options Selected

Minor surgery

Elective Major Surgery

Prescribing Medicines

IV fluids

Closed treatment of a fracture

So, you need one of each category to qualify Risk as a moderate data point

Listen, this system is complicated here.....My gut tells me that you should not count on using Risk as 1 of your 2 required points to qualify MDM as moderate complexity.

My take home on MDM is-Always review your own data, Always review old records, 

Always document new problems and demonstrate your work up of them......If you do these things you will likely qualify for moderate MDM

Now that's over, let's look at a Comprehensive Exam

Comprehensive is defined as 

1. "A general multisystem examination"

2. " A complete examination of a single organ system"

Organ systems are:

Eyes

Each Extremity, I repeat EACH Extremity

Ear, Nose,Throat and Mouth

Eyes

CV

Respiratory

GI

GU

Musculoskeletal

Skin

Neurologic

Psychiatric

Heme/Lymph

If you set up a template of your exam as such, you will do well in documenting these events. The take home here is that to be complete you would need 2 bullets for each of the 9 systems.......Ah silly coders, they have to be so precise in defining complete.....do they really know what complete means?

I go over bullets and the exam in prior posts 

This is a gimmee here. Anyone would do this for a new patient......Anyone......Count Complete physical as one of the 2 Categories filled

Lastly,

Complete History. This bugger is considered the Highest Level of History. Which means often people try but fail at performing this.

This history includes:

1. Chief Complaint

2. "Extended" HPI

3. Review of systems related to the problems in the HPI PLUS all other systems

4. COMPLETE Family, Social and Past Medical and Past Surgical History

I will go through each in detail, but suffice to say.....you should be doing these things for ALL new patients if you want to code a 99204.....I actually do this for ALL of my new patients....I will explain why shortly...

The big question here is likely to be What is a COMPLETE PM/PS/Soc/FamHx (PFSHx)......One thing it isn't is NonContributory.......It is at a minimum-Parents, Siblings AND Children! I do grandparents too!

This includes Medicines and Allergies! I repeat, this includes medicines and allergies....

I plan on covering this in another post, but just keep these tips in mind.

Is the patient married? Are they employed? Have they had education? Do they have exposures? Sex? Drugs? Rock and Roll? 

Remember, nearly all outpatient codes require some elements of this here. So it is just good sense to do this at EVERY encounter.....

And most importantly, the PFSHx can be taken by another person, OR EVEN a Form......

What does this look like in real time? 

Initial visit for a 59 year old woman with HTN, Obesity, OA. She has a complaint of palpitations with some occasional dizziness. Her PMSFHx includes TAHBSO for DUB 15 years ago. She has not been seen for 5 years.

If this new patient is also here for a complete physical exam....there is something I need to share with you.....it is called Modifer 25....the name of this blog! 

Want to learn coding and billing? Want to put 5 billion back in your pockets? Join us....email us at modifier25@gmail.com

Fridays are Fun Days, Wolfram Alpha Fun!

I will skip writing about coding on Fridays and instead will focus on technology that will bring us closer to removing some of the layers of ineptitude in medicine and the business practice.

Wolfram Alpha is going to change how we understand coding and in fact if done properly, this computational system could put the Athena Health service which I mentioned wanting to charge me 10,000 USD for a set up. If done properly by placing the rejection claims on the internet where Wolfram Alpha could access it. 

Athena Health brags that they have 17,000 US physicians dumping into their database........What if the 700,000 physicians dump this information onto the Internet so that Wolfram Alpha can access it?

It may just so turn out that by writing apps around Wolfram Alpha, we may actually be able to replace the billing software systems as well. 

You see, the CPT code and ICD9/10 system were made for our benefit. Not to cost us money. It will only take a small matter of time before the inevitable has happened.

Wolfram Alpha is soon going to be Wolfram Beta, which will then be Wolfram.....

And we will have just put billions of dollars back in the pockets of doctors.

But it starts with you......joining us and putting this info online.......or at least blogging with us....

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Physicians Undercode out of Fear and Emotions.

This article is a must read. It turns out that Physicians often overcode Evaluation and Management codes. At least according to Medicare stats. Which is why you should pay attention when you read this article. The take home points???

1. “Some physicians will code every office visit as a 99212 just to stay under the radar and avoid a Medicare audit,” says Ginny Martin of Healthcare Consulting Associates of NW Ohio in Waterville. “However, coding everything the same can initiate an audit as well.”

2. Medicare data suggests that, for evaluation and management services, overcoding is far more common. Medicare providers overcode with the ubiquitous 99213

3. “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”

4. For a 99214, the nature of the presenting problem(NPP) is usually of a moderate to high severity, in contrast to a 99211, where the NPP is usually minimal. Pinning down the NPP level is the key to accurate coding

5. Arrive at a tentative NPP as part of your differential diagnosis once they take a comprehensive history. We use 3 gen pedigree and extensive social history. Include a field for the NPP on your hard-copy encounter form or in your EMR

6. Use the whole ICD9 Code: “I’m stunned by how many doctors don't do that. A 250.00 means Type II diabetes that’s under control. What if it’s not under control? That’s 250.02.”

So to summarize, use the right code, be realistic with your encounters and make this PART OF YOUR CLINICAL PRACTICE. By using these, you begin to scrape away the magic of the billers and coders.....How do you do this? Keep reading, we'll get there.

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