99212 and You......

In keeping good faith with the readers of this blog, I am going to move to a "Level 2" Established patient visit. E and M University has some stats from 2003 on this, which may or may not be useful.....

Only 6.7% of Internists used this code in 2003. My guess is that it still is that way....

Why? Well, so often we do more work than the 99211 and 99212. Why? Well, this code requires

1. A problem focused history

2. A problem focused exam

3. Straightforward Medical Decision Making

Do you all remember how each of these categories is judged?

History is judged on:

A. Chief Complaint

B. HPI

C. Review of Systems

D. Review of Past Family, Social, Medical History.

A 99212 requires a Problem focused history which means you have to document a Chief Complaint and ONE HPI element. Just One.

What are the HPI elements? Well first, you need to know that there are only 2 types of HPI-Brief and Extended. What's the difference? Glad you asked. The difference is HUGE and I just told you what was required for Problem Focused.....

Now the elements

A. Location
B. Quality
C. Severity
D. Duration
E. Timing
F. Context
G. Modifying Factors
H.Associated Signs and Symptoms

That's it......you ONLY need one for a problem focused history. But for anything else you need 4 Elements, or the status of 4 or more chronic problems.

Think about it. A patient has pain, we ASK about PQRI (That's 4 BTW) but do we ever document 4? We should.

Now on to the problem focused exam.....

This is probably one of the funniest of them all. Problem focused exam requires ONE Bullet in ONE organ System........

Do you remember the Organ Systems? You can read about them and the bullets at this old post of mine.

But that would be tantamount to say. I took the Vitals......or I heard the heart.
We obviously are doing much more than that. Which is why most often our physica exams fall in the Expanded Problem focused, where you require 6 bullets in one or more organ systems. BTW you get 1 bullet for Vitals and One for General Appearance. Which you should do every time! Then you listen to the heart. Murmurs? No. 1 bullet, PMI shift No? 2 Bullet that's 4 bullets. So do you think you could get 2 more? Yes, most often we do. Which is why you rarely use the Level 2 99212...

In fact most things when a patient follows up are 99213 OR 99214 which will be covered shortly.....

But lastly in case you didn't make one of the previous 2 categories....you always have medical decision making. In the case of 99212 the level of decision making is straightforward medical decision making. Which in essence means you didn't need t o review or to think.....

What is straightforward MDM?

Straightforward Medical Decision-Making is the lowest level of Medical Decision-Making. It is impossible not to qualify for it.

It requires that you meet 2 of the 3 categories with One Point in each OR one category and MINIMAL Medical Risk.
What does that entail? Well, you can review my medical decision making post or you can just see right here

MDM is broken up into Problem Points, Data Points and Risk of Morbidity or Mortality from Disease.

Problem Points are
4 Points-New Problem, New Work up
3 Points-New Problem, No Work Up
2 Points-Established Problem, Worsening
1 Point-Established Problem, Stable

Data Points are
2 Points-Independant review of EKG or Radiology or Specimen
2 Points-Review of Old Records
1 Point-Ordering or Reviewing Labs
1 Point-Discuss results with OTHER physician
1 Point-Ordering tests (EKG/CXR/Cath)
1 Point-Decision to obtain old records

Risk in this case is Minimal Which means "Self limited or minor problem"
Risk is determined by 3 Things
1. Presenting Problem
2. Diagnostic Procedures
3. Management Options Selected

Still Conufsed? You can check the Table of Risk at EM University for further clarification.

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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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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!

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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