# 99214 vs 99213



## kristy2

Can anyone help point me in the right direction!

I am working on a chart audit (first one) for a physician whose 99214 visits have been down coded by CMS to a 99213.  In each case the physician treated patients with multiple (3 or more) chronic conditions that were all in stable condition.  No additional work up or change in medications. 

He knows his documentation guidelines well, and feels that because there are multiple chronic conditions documented it qualifies as a level 4 through the HPI and MDM.

I need some supporting documentation that supports overarching.  I have been on the CMS website and reviewed the E&M documentation guidelines.  I am having troubles finding documentation to support my rational that will be clear to the physician.  Does anyone have any ideas or suggestions?????  Does anyone know of an article I can reference on this subject?


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## Sandy Stevens

It is not always possible to support higher E/M levels even if it "adds up"; it's based on the nature of the problems.  The ability alone to generate a level of history and exam equal to a 99214 is not the basis for billing the code. So, for some patients, a 99214 might be appropriate; but a 99214 is not universally/categorically the level of service to be billed when a patient with 3 stable problems is evaluated. 

Are the problems actual disease processes/comorbidities; underlying problems with manifestations; consider and document when problems managed by other physicians affect your MDM. 

It doesn't matter that the 3 chronic problems, e.g., HTN, hyperlipidemia, DMII were stable. It doesn't matter that there were no changes in management of the problems, or new interventions. The overall level of MDM is considered Moderate when managing these 3 chronic conditions; and that's even without Rx mgmt. 

I found many physicians fall short in developing a History to include a more meaningful chronicle of a problem since onset or last visit - especially with chronic problems.

I've attached advice that I give to my physicians; all 98 of them/11 specialties (examples of the problems in the attachment are primary care-type)

Sandy
p.s. I can't tell if it's attached or not.  : /

Holler if it's not or if it is and found it helpful.
sadams@heritagemedical.com


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## LLovett

*Which Medicare carrier?*

I am really curious to know who your carrier is. Some carriers have stricter E/M guidelines than the official CMS guidelines. 

If CMS downcoded him then they should provide the reasons why and that should be the only support you would need. If he still disagrees, fight them on it. 

Laura, CPC, CPMA, CEMC


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## Sandy Stevens

Wow - I haven't been in the forum for a long time - review from my email and admittedly, don't read them all, but I do save them in my forum file, until I get around to it. I’m only 254 behind. I'm in now, looking for something else. 

But the answer is Cahaba. I'm in TN. It was Cigna in way back when. 

CMS Documentation Guidelines is the criterion by which, we all follow, no matter the MAC or other third-party payer.  I use 1997 guidelines, and teach that in my practice. However, the fact of the matter is, and I said this earlier today and nearly every day to a physician – Determining the level of E/M service, is not strictly about “counting” elements/number of dx, ROS, bullets, etc. If it were, the Bell curve/benchmarks would all lean to the right. 

It is the nature of the presenting problem and risk factors affecting the physician's MDM that is the overarching factor in supporting a level of E/M service. The History and Exam used to determine the level of E/M service should be commensurate with the type of MDM required in order to diagnose and treat the patient. That doesn’t mean that the physician can’t obtain a comprehensive Hx or perform a comprehensive exam. It simply means that only that which is medically necessary in order to diagnose and treat the patient should be used in determining the level of E/M service. 

ss


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## Sandy Stevens

*99213 vs 99214 or 5*

Wow - I haven't been in the forum for a long time - review from my email and admittedly, don't read them all, but I do save them in my forum file, until I get around to it. I'm only 254 behind. I'm in now, looking for something else. 

But the answer is Cahaba. I'm in TN. It was Cigna in way back when. 

CMS Documentation Guidelines is the criterion by which, we all follow, no matter the MAC or other third-party payer.  I use 1997 guidelines, and teach that in my practice. However, the fact of the matter is, and I said this earlier today and nearly every day to a physician – Determining the level of E/M service, is not strictly about “counting” elements/number of dx, ROS, bullets, etc. If it were, the Bell curve/benchmarks would all lean to the right. 

It is the nature of the presenting problem and risk factors affecting the physician's MDM that is the overarching factor in supporting a level of E/M service. The History and Exam used to determine the level of E/M service should be commensurate with the type of MDM required in order to diagnose and treat the patient. That doesn't mean that the physician can't obtain a comprehensive Hx or perform a comprehensive exam. It simply means that only that which is medically necessary in order to diagnose and treat the patient should be used in determining the level of E/M service. 

ss


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