Avoid Audits! Use Codes 99214 and 99233 Only When Merited
Published on Fri Sep 01, 2000
The Health Care Financing Administration (HCFA) is watching providers usage of evaluation and management (E/M) codes and paying special attention to codes CPT 99214 and CPT 99233. In a letter to physicians earlier this summer, HCFA warned that auditors would begin closely monitoring these two codes. Coding professionals should be sure any anesthesia E/M services being billed with these codes are legitimate, and that the patients record includes documentation to back up the use of these two codes.
The Codes in Question
One of the codes cited by HCFA relates to office or outpatient evaluation, and the other deals with subsequent hospital care. The definitions are:
99214 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; and medical decision-making of moderate complexity)
99233 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; and medical decision-making of high complexity)
HCFA auditors say 99214 and 99233 accounted for a large portion of coding errors in the last two audits. Their letter confirmed that documentation for many of the services was only sufficient to support the services covered by codes 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem- focused examination; and straightforward medical decision-making) and 99231 (subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a problem-focused interval history; a problem-focused examination; and medical decision-making that is straightforward or of low complexity), which are both of lower complexity than 99214 and 99233.
What Happens Now?
Evaluation and management of patients usually is included in the global fee for most anesthesia services provided. Some practices rarely use them and will not be affected by the scrutiny. But with the growth of pain management practices, more providers are using E/M codes more frequently. Providers and coders should pay close attention to the criteria for each E/M code to ensure that the best-fitting codes are billed for the situation.
Appendix D of CPT 2000 lists clinical vignettes that include examples of the use of code 99214 for anesthesia and pain management. One of the four clinical vignettes states that 99214 might be reported for an established patient with new onset of low back pain. [...]
