Optimize Pay Up for High-Level E/M Visits
Published on Sat Apr 01, 2000
CPT code 99214 is an established patient visit code often reported by cardiology practices, and usually it is completely justifiable because of the nature and complexity of the problems patients with cardiovascular conditions present.
Some cardiologists, however, fearful of tossing up a red flag or uncertain about the documentation requirements, unnecessarily undercode these office visit. Others, meanwhile, bill the 99214 excessively with scant documentation, based on an ill-advised notion that virtually any visit to the cardiologist merits this relatively high-level evaluation and management (E/M) service.
For that reason, many carriers now are carefully scrutinizing 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: detailed history, detailed examination, medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patients and/or familys needs. Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family) claims, says Terry Fletcher, BS, CPC, a coding and reimbursement specialist in Laguna Beach, Calif. Among office visit codes, the number one target for audit is 99214, Fletcher says, noting that some Medicare carriers now are asking for records on every third patient for whom a 99214 claim has been submitted. Cardiologists are being subjected to Medicare prepayment and postpayment reviews, she adds.
Documentation that consists of patient doing well; will return in six weeks doesnt come anywhere near satisfying the requirements for a level four visit, Fletcher says. Just because the patient is visiting a cardiologist doesnt mean the E/M code can be flat lined at level four.
The increased Medicare attention paid to 99214 claims, spurred by excessive coding, in turn has resulted in fewer 99214 claims by more cautious cardiologists, even when they have fulfilled the requirements for a level four visit, she says.
Other cardiologists, meanwhile, may have performed a level four service but dont document it correctly. Cardiologists need to be informed and educated, and periodic chart reviews should be performed to enable them to receive the full reimbursement that they are due, says Stacey Elliott, CPC, business office manager with COR Healthcare Medical Associates, an 11-physician cardiology practice in Torrance, Calif. Too often, the cardiologist performs a level of service but unfortunately documents a level much lower. And sometimes, the physicians lack of documentation prevents a bona fide service from being reimbursed at all.
Dont Underestimate Decision-making
Fortunately, satisfying the requirements for 99214 is not as difficult as many cardiologists believe, Elliott says. E/M services comprise of three components: history, examination and medical decision-making. For established patients, only two [...]
