# 99215 Documentation/99213 Appropriate



## Lassal423 (Jul 31, 2012)

What do you think about documentation that supports 99215 (Comp hx, Comp Exam, Mod MDM), but 99213 is what is justified for an established patient.

With the use of EMR templates, I see this more and more.  The documentation supports the higher level, but there really isn't medical necessity to justify the higher code.

How would you code these visits?

Lora


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## S;LDFJGjj12@ (Jul 31, 2012)

I have another name for EMR templates, Auto Population Gone Wild !


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## Orthocoderpgu (Jul 31, 2012)

Your premise is wrong. Your code cannot be higher than the MDM. Your example given would be a 99214, not a 99213 or a 99215.

For a 99215 you need to have four problem points and High risk on your risk table chart. In order to bill a 99215 you need to have a condition that is SEVERLY EXACERBATED, or a real threat to life, limb, organ system or organ. You should almost never see a 99215 when the patient keeps a scheduled appointment unless it's based on counseling time. 

Whoever has set up your EMR needs to adjust the settings so that the code it spits out is not higher than the MDM. We recently switched to an EMR too and the coding has become more critical since we have to be able to point out mistakes made by the EMR.


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## LindaEV (Jul 31, 2012)

E/M Coder said:


> Your premise is wrong. Your code cannot be higher than the MDM. Your example given would be a 99214, not a 99213 or a 99215.
> 
> For a 99215 you need to have four problem points and High risk on your risk table chart. In order to bill a 99215 you need to have a condition that is SEVERLY EXACERBATED, or a real threat to life, limb, organ system or organ. You should almost never see a 99215 when the patient keeps a scheduled appointment unless it's based on counseling time.
> 
> Whoever has set up your EMR needs to adjust the settings so that the code it spits out is not higher than the MDM. We recently switched to an EMR too and the coding has become more critical since we have to be able to point out mistakes made by the EMR.



Actually, I don't think she is wrong. Remember you only need two of the three key components. Truth is you _*shouldn't *_code higher than the MDM, but you _can_, and that is what the EMR systems are doing. Obviously its not "right" ethically to do so, and the MDM _*should*_ drive your code selection. 

When I audit physicians and their coding is based on the amount of documentation and not the presenting problem, I look at it as an oppprtunity to educate them. Use the CMS guidelines where it says the level of E/M is not driven by the amount of documentation but by medical necessity. Also use the clinical examples that can be found in the back of your CPT book. 
Ask them to compare- would they agree that a 86 year old with bronchitis who has co-exisiting conditions and needs a prescription would justify a level 4? (Most will say yes) Then ask them does this healthy 16 year old with bronchitis deserve a level 4 too just because it is a "new" problem needing a prescription? Probably not. 

I personally think the EMR's are killing the quality of documentation instead of helping!


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## sullivak (Aug 2, 2012)

I so agree!  I'm astounded by the level of documentation I have been seeing lately.  Not only is the coding often overinflated, but the quality of the documentation has also suffered.  

In a number of EMR docs I've seen, narrative seems to have completely disappeared from the document, leaving nothing but empty fields, "Other"s for Chief Complaints, and "canned" ROS and exams.  With the current CMS push toward EMRs and penalties for doctors not using them, I think some serious attention needs to be paid to these crucial documentation quality problems.  No one can convince me that this does not have a negative effect on patient care. 

Sorry for the soap box, but I couldn't resist...


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