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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Sitck with the Outpatient Codes, Please. 99211

Ok, Ok. I asked a read this week if they would rather have me review further inpatient or out patient codes. They begged me to stick with outpatient codes. So In response to that, no problem.

I figure I can walk you right through some outpatient cases which will help understand how your return patients match up. But first, let's talk a little about the established patient. This is defined as someone who has been seen by you or a physician in the same specialty in your group within the previous three years.There are five levels of care for this type of encounter which all require documentation of TWO out of THREE key components.

These are the absolute same components as you will see for most E and M visits.....

Yes, our lovely friends History, Physical and Medical Decision Making (MDM)

These components are broken down into several subgroups which in the end ultimately determine how much you get paid for Evaluation and Management codes.

The best part about established patients is that you do not have to meet such a high barrier to bill at the higher levels. Instead you only need 2 of 3 components to be at the highest level of your biling. Which is a heck of a lot nicer than the 99205 trainwrecks which require 3 of 3......

Let's talk about the simplest of these today. The 99211. The 99211 was designed as a quick 5 minute visit for follow up of one issue. In fact, this issue was not even thought to incur actual physician to patient face time.

This is a stable and acceptable BP check, done by nurse or PA. Let's look at it.

A 57 year old man comes to the office for a BP check. It is 120/80.....perfect. 

The patient has NO OTHER COMPLAINTS OR NEEDS at this time. I repeat, the patient has NO OTHER COMPLAINTS OR NEEDS at this time.

If he has ANYTHING ELSE....this code is not for him and he should be seen by an MD...... 

99211 equals one problem, no change in management or simple change in management. 

This visit does not require any hurdles. In fact the AMA considers this a 5 minute episode.....so If you have gone past 5 minutes, you need to look at other codes. In short, NO ONE REALLY CODES a 99211. In 2003 according to E/M University, 5% of all office visits were this code and the average reimbursement was 21 USD.

Take Home Point, If you've spent more than 5 minutes, you shouldn't use this code.

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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! 

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Middle of the Road 99203

According to EM University, in 2003 this code accounted for 39% of all documented office visits in 2003. I wonder why we don't have any further data on this. Wouldn't it be fantastic if we could see who was coding what and how often? Imagine if we could have a website that would present this information to physicians yearly and then match it against your rates? Well, there are some pay services that allow this for subscribers of their service....

I think you know how I feel about someone taking your data, compiling it with others AND THEN SELLING IT BACK TO YOU!

Frankly, that is just bull......I think it should either be outlawed OR we should be given FREE ACCESS to this.

It is after all, OUR DATA.

So with that little rant out. Let me tell you about a 99203

A 99203 is also called a Level 3 New Office Visit. What is it?

This office visit requires 3 key components

1. A Detailed History

2. A Detailed Examination

3. Medical Decision making of LOW complexity

Why do I point out Low complexity? Because, I think we may actually be coding too much of these and may instead need to be coding more 99204s and 99202s....

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" tp incude a limited review of:

A. Family History

B. Social History

C. Past Medical History 

All directly related to patient's problem.....

2. Detailed Examination-Requires an "Extended" examination of the affected body area or organ system AND other symptomatic or related organ systems.....

"Extended Examination"- requires 12 data points/bullets.

If you want to learn more about bullets you can see it here.

3. Lastly, Medical Decision Making of "LOW COMPLEXITY"

Which requires

1. Limited number of Diagnoses or Management Options

2. Limited amount of data to review

3. Low complexity of data to review

4. Disease with low morbidity or mortality

So the question remains...."What does this look like?"

Initial offive visit for a 67 year old woman with hypertension, new to the area. She has had no problems with her BP while on a diuretic and home bp monitoring. She brings in her log.

You are expected to do the same things that you would for a 99202

So why do I think we are using this code too much? Here's the question.....would you do such a thorough History or Physical in a patient with well controlled HTN?

Probably not, which would then bump you down to a 99202. 

But what about well controlled diabetes? The mortality and morbidity is higher and you would do more work.....thus a 99204, which I will cover tomorrow......

You see, by choosing middle of the road, we may be coding wrong......

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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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