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PACdan

Office visits level 3 vs. 4; new vs. established

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Hello all,

 

It's hard to believe I'm only months from graduating now. My strong interest in Family Med has not wavered, and in fact I had an excellent rotation in a small clinic who's environment is one I aspire to work in. That said, I got to see a little more of the inner workings of coding & billing and I know this will be part of my future practice. Most patients we saw were established (85%), and got coded as either level 3 or level 4 visits. I've looked at the documentation and time requirements between the two and it seems that the divide really comes between levels 2&3 and 4&5. The lower levels being single problem focused (narrow or expanded) and the upper levels being a comprehensive exam (i.e., for multiple issues).

 

When looking at the Medicare reimbursement schedules, I hear that most private payers/insurers follow those schedules. Have those of you in outpatient FM found this to be true? As a student I've gotten quite expedient at initial H&Ps (and usually sent to do these for the residents), so I'm used to writing more comprehensive notes. But I assume that the way the patient presents and their PMH/co-morbidities dictate what type of level/note you write for that visit? Thanks for the input, just trying to map the jungle before I get air-dropped in.

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The level of risk is the biggest determinant in coding level.  Once the level of risk is determined, essentially based on the assessment and plan, the level of documentation should be at least as high as needed to support the maximum reimbursement for that risk level.  This only makes sense, really: if the level of risk is high enough, you really SHOULD have taken a good enough H&P or done a thorough enough exam to code for that level.

 

Considering that most things that family med patients show up for (including prescription drug management, two or more stable chronic illnesses, and new problems with uncertain prognosis) merit moderate level risk, coding a 99213 for an established patient should be a rarity.  Moderate risk is well defined, and provider gut feel ("this isn't that bad") does not play into it at all.

 

Don't upcode.  Don't downcode.  Code to the level consistent with documented risk, do it well, and make sure your documentation meets both medical needs (things the next provider will need to know) as well as coding needs (checking the boxes to demonstrate you worked "enough" to be reimbursed at that level).

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I'm attending a billing & coding workshop on Tuesday. I hope to get a clear understanding of this for the first time in my life! I'll let you know what I find out!

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Since my visits have do not have much of an exam after the first consult, I bill on time. It is complex discussions on new treatment options for patients who have failed many prior treatments. One day it dawned on me when I was staying after work to dictate, that my charting time was volunteer work because I did not get paid for staying to work on charts. Also, a big part of my charting was to document what happened in the room in case the chart notes were audited by the insurance company (I need very little charting for good care). So, a light went off. Here I was working for free for the insurance companies.

 

So now, I have long appointments. I listen intensely to the patient, carefully plan our next steps and I type my note as we are meeting. Then, at the end of the appointment, the note is done and faxed to the referring provider and I don't stay after work or even chart during lunch. I bill the insurance for that face to face time and include my charting, because it is in the context of face to face meeting, as part of that time.

 

Now if you want to optimize collections, I'm sure that you could bill at a higher rate than I do by compacting exam features in a shorter time period.

 

But my shortest return visits are 20 minutes and my longest follow ups are 45-50 minutes. So based on the table below, I follow the clock precisely and bill mostly 99214s and some 99215s. Rarely do I bill at 99213. But I don't see nearly the number of patients per day as some of you.

 

 

Codes

99211

99212

99213

99214

99215

Times

5 min.

10 min.

15 min.

25 min.

40 min.

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I was at a Medicare seminar and they indicated to avoid getting flagged for audit most of your codes should be 99213 and 99214 and if you're not admitting a patient to the hospital avoid 99215 altogether.

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I think we should be very honest and never over-bill, but don't let intimidation force you to under-bill. I have endured two Medicare audits. The only thing, due to my misunderstanding, they found was me billing as a new patient when they considered it wasn't. However, I think I was right and the private company doing the audit was wrong, but I didn't have the time or money to fight it. I paid them back for those bills. But the "New Patients" were patients I had seen in a different practice, with a different SP and a different specialty. However, when they came to the new practice with the same or slightly different complaint, they could not be seen as a "New Patient" at that practice but only as a return acording to the auditor. But if you read the rules, if it is a different specialty and a different practice it is a New Patient.  However, they didn't question any of my 99215s when they saw the documentation. So don't over bill and don't under bill but most of all, make sure your chart notes supports the 99215 (or whatever billing) and don't worry about an audit. I have had threatening letters from Regence twice that they could audit me for using too many 99214 and 99215s, and I say, "I welcome your audit. I will accommodate your visit any way I can. Help yourselves and go for it."  Read the rules for 99215 and if you meet the rules bill it.

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https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

 

There's a lot of reading there, but those are the guidelines. There are basically 3 key components, the history, exam, and medical decision making. There are specific requirements for each of these to reach the level 4, but you only need to reach level 4 in 2 of those 3 key areas. It's too complex for me to explain in a post, but that guide should help.

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One of the challenges I've encountered (aside from learning medicine as a whole (new grad)) is coding. 

 

I've come to the realization pretty much any visit (unless it is a super straight forward person with a straight forward problem) can be a 99214 (level 4).

 

The three components are History, exam, and MDM.

 

Your History and exam will always be at a level 4, unless you really are a negligent provider. To bill at a level 4 for history, you need atleast 4 elements of what is going on (aka onset, provocation, duration, severity, etc). You should also comment on the family, PMH, or social history (I see you are still smoking despite having that cough). The review of systems should always be more than 2 systems (very easy). Your exam will always be at a level 4, as you should always listen to heart and lungs (you only need 2 groups), but you can add in constitutional and psych for every patient. 

 

The thing that becomes difficult is the MDM. My employer requires that to bill at a level 4, one must be MDM (so MDM plus history or MDM plus exam gets you a level 4). You can do this by a couple of ways. Example: a patient comes in who has diabetes and HTN who presents with a straight forward URI/cough. You should comment on your assessment and plan about the status of chronic problems. Example: diabetes: controlled, monitoring sugars, following with endo. Example: HTN, on lisinopril, BP elevated in office today, will continue to monitor. You can also have a straightforward problem but if you are providing prescription management: aka tessalon for cough, guaifenisin, etc.....you are billing to a higher level because your decision making is more complex.

 

Let's use our example:

 

57 year old male patient presents with cough. He has hypertension and diabetes. 

 

History: You find it is 4 days duration, worse at night, productive, better with mucinex, worse after smoking his morning cigarette. No fever, no diarrhea, no vomiting, no chest pain/palpitations/SOB/dyspnea.He has a family history of lung cancer, so he's worried. His sugars have been under good control, his last A1C was 7.2 He takes his BP at the grocery store occasionally. He is still smoking (From a coding standpoint: you have 4 elements of the history, you have family history, you have a social history, You have also done atleast a 4 part ROS) You additionally have commented on 2 chronic problems (dm plus HTN) History: Level 4

 

Exam: Clinically, he looks well. Mood normal. He coughs occasionally. PERRLA, TMs clear, mild nasal congestion in nares, throat non-erythematous, neck is supple, lungs CTAB, heart RRR, no mrg. (you have done a level 4 exam. You have done atleast 6 body systems on exam) (Constitutional, heent, psych, resp, cardio, neck (you really only need 2 for level 4). Exam: Level 4

 

MDM: Straight forward bronchitis/URI. Not much to do right? Here is where most people would avoid the little bit of extra work to get to a level 4. Patient requests "something for cough". You prescribe tessalon perles. You have gone up to a level 4. In your MDM, you could also build to a level 4 without prescription management by discussing the status of 2 chronic problems (dm and HTN) and next steps (aka if worse, would do CXR, would prescribe ABX in 1 week if not better, etc etc). You can bill to a level 4 because you have the status of 2 chronic/stable problems and 1 new problem that is new to the examiner/unstable. 

 

You should obviously never bill higher just for the sake of billing higher (aka don't prescribe a med just to get to a level 4). But if you are doing the work, you should get paid for it! Almost anything in primary care can be a level 4 if you do the right amount of work, ask the right questions, and document appropriately. 

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It's not just your employer requiring MDM plus either history or exam to bill at a certain level.  Those are the medicare rules for established patients.  For new patients, you must meet all three criteria at a certain level to code at that level.

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I'm a newish PA, two years, and I've already been audited. It isn't scary as long as you know what you are doing. All I got was a sheet of paper showing me that the auditor agreed with the billing codes that I used. I generally have rules of thumb that help me determine complexity. 

99213: (occasional billing) 1 or 2 chronic problems that did not get worse. Also acute problems that don't require drug management. 

99214: (95% of time billing) 3 chronic problems (period). Acute problems that require a prescription. Any problem that takes at least 25 minutes of discussion. 

99215: (I do bill these infrequently, and I'm comfortable with what I use this for.) Major problems that require a fair amount of work. Imaging, discussion with your supervising physician, most things that you find concerning findings (higher risk) and send to the ER immediately. Also!!!! Patients that require more than 40 minutes of discussion (this does not have to be the same problem). 

If you bill for time, you should clearly document what your discussion was about. Also annotate if the patient had any issues that caused discussion to go longer than anticipated. (Mild cognition impairment, psychiatric comorbidities.) 

Sometimes you do more work than what you can bill for, and in these cases remember you have modifiers. You can easily do a 99213 with a 25 modifier to add a simple/moderate procedure that didn't take much time. Earwax removal, sutures, trephination, pelvic exam are some of the ones that come to mind immediately. 

 

Another good thing to remember is that the complexity of your visit can help you tailor your notes so you are not _over_documenting. Not that there is anything wrong with it, but it is fairly time consuming. For example, an acute problem for a 99214 requires only 4 HPI elements. So pick 4 of OPQRST or Location/Quality/Severity/Duration/Timing/Context/Modifying/Associated signs/symptoms. 

A good example of this would be:

Patient is a 32 y/o female who presents for the evaluation of dysuria. She has had 3 days of symptoms, which include a 3/10 lower abdominal pain. Her symptoms are lessened slightly with Azo. 

Complexity wise, this satisfies the 99214 requirement for your HPI. (Do please add any other important details, like fever or other major symptoms.)

 

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