wilso2ar Posted July 30, 2014 Share Posted July 30, 2014 I wonder if there is something I'm missing here. My 3 y/o has obstructive sleep apnea diagnosed by sleep study. Was set up with our ENT that we already have seen in past for uncomplicated PE tube placement. He is going to remove tonsils and adenoids. My kid is otherwise healthy. O/V took all of 12-15 minutes. I know that he did not cover all the required ROS and PE to meet level 5. Is there something I'm missing from an ENT specialist side that would constitute a level 5 as far as decision making, reviewing data etc? Or is this guy just trying to collect as much as possible from my insurance. I trust this surgeon, but it is surprising how much my opinion of him has changed due to this bill. It's not about the money, It's the same copay for me. It's about the integrity. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 30, 2014 Share Posted July 30, 2014 I don't have the answer for you, but I've wondered the same thing over the years with regard to diagnosis/level of care coding. Not even being experienced from a coding perspective I know enough to know that there needs to be a decent amount of material covered to hit a 4 or 5 level (which never seems to be the case based on the information solicited). Link to comment Share on other sites More sharing options...
coloradopa Posted July 31, 2014 Share Posted July 31, 2014 I wonder if there is something I'm missing here. My 3 y/o has obstructive sleep apnea diagnosed by sleep study. Was set up with our ENT that we already have seen in past for uncomplicated PE tube placement. He is going to remove tonsils and adenoids. My kid is otherwise healthy. O/V took all of 12-15 minutes. I know that he did not cover all the required ROS and PE to meet level 5. Is there something I'm missing from an ENT specialist side that would constitute a level 5 as far as decision making, reviewing data etc? Or is this guy just trying to collect as much as possible from my insurance. I trust this surgeon, but it is surprising how much my opinion of him has changed due to this bill. It's not about the money, It's the same copay for me. It's about the integrity. So for 99215 you need 2 out of 3 of a comprehensive history, comprehensive exam and high level decision making, For the history, if you had filled out previous work that documents the elements you can pull that forward and just include the HPI. For the ROS you can ask any other problems and document a no answer to that (although I tend to go through all systems). For the exam you need 2 bullet points in 9 systems. However, for specialties you can use the 1995 rules and do a comprehensive exam of one organ system of which ENT is one system. For medical decision making you need 2 out of 3 of problem points, data points and risk. Risk is easy since you are making the decision for surgery. You also have problem points since you have new problem and an established problem. Can't say if you have data points based on the description. Without looking at the documentation its hard to know exactly what happened but, given the decision for surgery it wouldn't be hard to justify it. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 31, 2014 Administrator Share Posted July 31, 2014 As I understand it, 2 of 3 of the history, exam, and decision making means either history+decision making or exam+decision making--in other words, you need decision making PLUS one of the other two. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted July 31, 2014 Share Posted July 31, 2014 Another life mystery. Why does this stuff have to be so convoluted? Link to comment Share on other sites More sharing options...
jmj11 Posted July 31, 2014 Share Posted July 31, 2014 What was the time factor? If he spent 40 + Minutes with you, describing the procedure, reassurance, post-op plan and etc, then yes, it was worth it. But if he marched you through in 15-20 minutes, then I'm suspect. I new a physician who automatically billed 99215 on all patients, usually spending 10 minutes with them and doing virtually no exam. That, in my opinion, was fraud and I no longer work with him. Link to comment Share on other sites More sharing options...
wilso2ar Posted August 2, 2014 Author Share Posted August 2, 2014 The time factor or lack thereof was my beef. 12-15 minute and minimal ros review. Heck, I don't know what he was using for multiple diagnoses. I just use this as an example to strengthen my documentation skills. Link to comment Share on other sites More sharing options...
coloradopa Posted August 3, 2014 Share Posted August 3, 2014 The time factor or lack thereof was my beef. 12-15 minute and minimal ros review. Heck, I don't know what he was using for multiple diagnoses. I just use this as an example to strengthen my documentation skills. Time is only one issue. Its guidance. The other reason its there is to determine when you can bill based on time and when you trigger prolonged time billing. It doesn't matter the time, if your documentation supports the rest. Like, I said, based on medical decision making its 99215. If you can cobble together the rest then its pretty easy. Link to comment Share on other sites More sharing options...
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