# Risk-based coding established patient 99214 vs 99215.



## candle99 (Apr 10, 2017)

I have seen a large variation in how different outpatient offices bill the same type of progress note.  If a progress note has a comprehensive history, comprehensive exam and moderate risk/medical decision-making, then technically it should qualify for 99215 cpt code.  There is an unwritten rule that auditors seem to lean toward that says the medical decision-making and risk should drive the coding of the note, and if there is insufficient risk to justify the comprehensive history and comprehensive exam, then these components are "medically unnecessary" components and should therefore be coded at 99214 instead.  There seem to be several opinions from coders regarding coding of notes with comprehensive history, comprehensive exam and moderate medical decision-making for established patients.

Coder opinion #1 - "An outpatient office should never code a level 5 visit, maximum level is 4.  Level 5 visits should be reserved for the emergency room."
Coder opinion #2 - These coders follow criteria exactly and ignore the tendency of auditors to emphasize risk driven codes.
Coder opinion #3 - These coders tend to code about 20 to 30 percent of these visits a level 5, mostly patients with higher risk and decision-making.

I wanted some opinions on how others tend to code (or see coworkers code) the following notes, 99214 vs 99215 in their own experience.

Scenario 1: 
History - 3 chronic illnesses or recurrences.  Urinary frequency.  Bronchitis.  Congestive heart failure.
Exam - comprehensive.
Assessment - Given antibiotics for urinary infection (recurrent) and acute bronchitis.  Congestive heart failure stable.

Scenario 2: 
History - 3 chronic illnesses:  Low back pain, congestive heart failure, epilepsy.
Exam - comprehensive.
Assessment - No change in medications.  Cong heart failure stable.  Epilepsy stable.  Wheelchair ordered due to declining gait.

Scenario 3:
History - 3 chronic illnesses:  Hypertension, diabetes, constipation.
Exam - comprehensive - agitation noted and somnolence.
Assessment - Antidepressant reduced in dosage due to somnolence.  Antibiotic given for suspected UTI pending urinalysis.  Hypertension, diabetes and constipation stable.

Scenario 4:  
History - 3 chronic illnesses:  Congestive heart failure, diabetes, hypertension.
Exam - Comprehensive.
Assessment:  Mild congestive heart failure exacerbation with increased edema, mildly reduced oxygen saturation compared to prior visit, diuretics increased.  Diabetes suboptimal control but no medication changes.  Hypertension stable.

Scenario 5:
History - 2 chronic illnesses - Parkinson disease, urinary frequency.  1 new problem - difficulty swallowing.
Exam - Comprehensive.
Assessment - Dysphagia - swallowing study ordered.  Urinary frequency - urinalysis ordered.  Parkinson disease - no treatment change.

Any input would be greatly appreciated.


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## CodingKing (Apr 10, 2017)

Some payers require MDM to be used in leveling and I find its a smart idea since you can easily get a comprehensive exam and history even though its not essential to the presenting problem. I assume they are not actually just writing comprehensive in for the exam. It seems odd that every single patient is getting a comprehenisve exam.


20-30% of level 5's would make many specialties outliers and at high risk of being audited. Usually its single digit percentages.


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## candle99 (Apr 10, 2017)

CodingKing said:


> Some payers require MDM to be used in leveling and I find its a smart idea since you can easily get a comprehensive exam and history even though its not essential to the presenting problem.
> 
> 
> 20-30% of level 5's would make many specialties outliers and at high risk of being audited. Usually its single digit percentages.



Thanks for your input.  I agree that 20-30% of overall visits coded as a level 5 visits is above average and could trigger an audit, with the percentage running about 8% the last I checked.  I want to clarify that I intended to mean that 20-30% of the visits with a comprehensive exam, comprehensive physical and moderate risk-mdm being coded as level 5, NOT 20-30% of ALL visits.  I was trying to get a sense of the gray line that is being used to differentiate between those deserving level 5 and those deserving level 4, using the above scenarios.  Again, I truly appreciate your input.  Thanks again for your insight.


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## LLovett (Apr 10, 2017)

*Weighing in*

This can be a bit of a tricky area. Unless there is reason not to (i.e. 100% of visits have comprehensive histories and exams) or a policy (either internal or payer) directing otherwise, I default to your coder opinion #2. The first opinion is completely unfounded in reality. The third opinion creates too much variation, these codes will be difficult if not impossible to reproduce by someone other than the original coder (if even they can reproduce them).

Hope this helps,

Laura, CPC, CPMA, CPCO, CPC-I, CANPC, CEMC


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## candle99 (Apr 10, 2017)

LLovett said:


> This can be a bit of a tricky area. Unless there is reason not to (i.e. 100% of visits have comprehensive histories and exams) or a policy (either internal or payer) directing otherwise, I default to your coder opinion #2. The first opinion is completely unfounded in reality. The third opinion creates too much variation, these codes will be difficult if not impossible to reproduce by someone other than the original coder (if even they can reproduce them).
> 
> Hope this helps,
> 
> Laura, CPC, CPMA, CPCO, CPC-I, CANPC, CEMC



Thanks for your reply.  I believe you are correct that using overall risk and mdm to drive note coding would cause large variations in the way different offices/clinics/coders/billing services code their notes.  In reality, this large variation is what I have seen.  As the other coder's reply shows, coders tend to avoid having their office coding flagged as an "outlier" according to their insurer, and possibly subject to an audit.  If an office's patients tend to be more complicated than average, then one would expect more cpt codes of 99215.  As the percentage of 99215 (the same scenario could apply to 99214) compared to all of their notes increases above the peer norm (possibly near 8 or 10 percent) then the office may get a notice from their insurer that their data has been flagged as an outlier.  The practice of insurers to judge all clinics against a broad "peer norm" tends to cause those clinics that service younger or less complicated patients to default to a higher level cpt code if the risk-mdm is slightly vague.  Clinics that see more complicated patients may default to lower level cpt codes, to avoid an audit or being flagged as an outlier.  I am curious how various coders handle situations where clinics have vastly different patients in terms of age and/or co-morbidities.  From a practice management standpoint, I would also be curious if offices/clinics have tended to adjust their patient population to more closely match the "peer norm" so that their statistical data from their insurer is not flagged as an outlier.  Thanks again for your input.


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## Orthocoderpgu (Apr 14, 2017)

Medicare (CMS) has stated that Medical Necessity is the over-arching factor in choosing a code. The reason for this is that with EMR the clinic staff document more of History, ROS & Exam simply because they are allowing the software to guide their actions. This leads to severe over coding.

Your debate on 99214 vs 99215 should not even be a debate. 99215 requires High MDM. I audited a clinic where every patient, no matter what they were seen for, had a COMP HX & COMP Exam. By the logic being used here, every E/M would be billed out as 99215.

And High MDM in an office setting is going to be rare. So billing 99215 based on MDM should be rare.

If you read the 1995 & 1997 guidelines carefully, you can see that they were written from the standpoint that a physician would never perform any part of an E/M visit unless it was medically necessary. I have literally had physicians tell me to my face that they document more than is medically necessary just to bill a higher code on multiple occasions.

So can you choose 99215 without MDM being one of the three factors? Yes, but you better be sure that every HPI, ROS, Exam and MDM element is medically necessary to that visit. Otherwise, it's up coded.

And yes, I understand the difference between medical necessity and MDM. Medical necessity is going to lead you to the correct MDM.


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