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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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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Do you risk stratify?

When you have a new patient, do you do a Framingham or Reynolds risk calculation?

When you have a postpartum follow up, do you do a depression screen?

When you have a geriatric patient, do you do a safe driver evaluation?

Do you calculate the risk of diabetes for patient that have family history of DM2?

If you do any of these things, then you qualify to bill for a 99420. 

A Wha? Yes, most coders that I have asked have no clue what this code is. 

99420 is defined by the AMA as "Administration and Interpretation of health risk assessment instrument"

All of my new patients get a Reynolds Risk upon return visit after I have their labs to calculate this risk.....

They all get billed for a follow up patient visit AND a 99420. They may also get other services, but they ALL get a Reynolds Risk.  

Why? It helps me know when to treat lipids and what preventative therapy to use. So why oh why wouldn't you use these tools? In fact, I argue it is the standard of care to use these tools......

And Now, you can bill for it. And get paid!

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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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