EM Coding Alert

Hint: Never forget medical necessity when selecting codes.

Ever since the evaluation and management (E/M) codes were updated in 2021 to make time and medical decision making (MDM) the leading code selection criteria, many practices are finding that they qualify for more level 4 visits than ever. The upside is that they’re bringing in more reimbursement, but many practices wonder whether the potential downside is that they’re putting targets on their backs.

Why? Because if you report more level 4 E/M visits than your peers, auditors could take a closer look at your coding practices.

The good news is that just because an auditor reviews your files, it doesn’t mean you’re doing anything wrong. But auditor scrutiny can come back to bite you if you aren’t coding your level 4 visits accurately.

Read on for tips on how to evaluate whether you’re at risk of upcoding accusations.

Get to Know the Level 4 Codes

When it comes to outpatient visits, the level 4 E/M codes are as follows:

• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.)
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)

As noted in the code descriptors, your documentation must include either 45 minutes or more of total time spent OR a moderate level of MDM before you can report new patient code 99204. For 99214, you’ll need to document at least 30 minutes of total time, or a moderate level of MDM.

Level 4 Codes Are Error Prone

The Centers for Medicare & Medicaid Services (CMS) listed 99214 as the most overpaid outpatient CPT^â code among Part B claims last year, resulting in $666 million in overpayments. New patient code 99204 wasn’t far behind, resulting in over $122 million in overpayments. With errors in these codes totaling nearly $1 billion when added together, you can be sure that auditors are reviewing claims for level 4 services, and practices are right to think they may get audited if they are billing a higher-than-average volume of services using these codes.

Having said that, your practice may be perfectly justified in reporting level 4 codes, and as long as your documentation is thorough and supports your coding, then an audit shouldn’t be a concern.

Your practice should perform quarterly self-audits to determine whether you’re justified in assigning level 4 codes to your E/M claims, and report the results back to the entire team. If you find that a lot of upcoding is taking place, perform training sessions so all of the providers, coders, and billers know how to code accurately going forward.

If your provider’s documentation supports a level 4 visit, you should report 99204 or 99214. But watch out for these hidden traps:

Failing to Confirm Medical Necessity

While you may feel you’re justified in reporting 99214 every time the provider spends 30 minutes with an established patient, that’s not always the case. You must be able to demonstrate medical necessity for every visit, or else the code isn’t billable. For instance, if the provider spends 15 minutes examining a patient’s sinus infection and then talks to them about their daughter’s upcoming wedding for another 15 minutes, you can’t report 99214, even though 30 minutes were spent with the patient.

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code,” CMS says in Section 30.6.1B of Chapter 12 of the Medicare Claims Processing Manual. “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation must support the level of service reported.”

Payers and auditors may view obtaining a higher-level component than medically necessary just to charge a higher-level E/M service as “gaming the system,” and so you should always confirm medical necessity for every visit.

Choosing a Level 4 E/M Code Based on Diagnosis Alone

E/M codes should never be driven by diagnoses. Don’t assume you can report higher-level E/M codes for sicker patients or that all “routine” E/M visits warrant lower-level codes. The documentation and medical necessity should be driving your code choices, not the patient’s condition.

This is true not only because some patients with serious diagnoses may stabilize, but also because some patients with less serious diagnoses may need additional attention.

Check these examples of how a Crohn’s disease diagnosis might produce different coding results.

Example 1: An established patient with Crohn’s disease reports to your provider with vomiting and fever. Your physician orders a round of blood/stool tests and a CT scan of the abdomen, recommends some dietary changes, and prescribes prednisone for the condition. The total time documented is 23 minutes.

Upon reviewing the documentation, you notice several diagnoses or management options, a moderate amount and/or complexity of data to be reviewed, and a high risk of complications and/or morbidity or mortality.

Despite the encounter time of only 23 minutes, this service merits 99214, due to the moderate level of MDM.

Example 2: An established patient with Crohn’s disease presents so the provider can see how they’re tolerating a new medication. The doctor spends 20 minutes evaluating their medication tolerance. The doctor then asks the patient their opinion of the new mail-delivery prescription service they used because the doctor is thinking of participating with it in the coming year. They spend 10 minutes talking about the pros and cons of the prescription provider, ease of use ordering prescriptions through it, and how well the technology works.

Although this visit lasted 30 minutes, the documentation won’t warrant reporting 99214, and you must instead report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded).

Reporting 99214 for Every Single Established Patient Visit

Some insurers raise red flags when a practice reports only 99214 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that.

Solution: Choose your E/M code based on the provider’s documentation, medical necessity, and the CPT^â criteria. Perform self-audits to ensure the providers, coders, and billers are coding appropriately, and provide training when coding levels fall short. This way, you’ll stave off accusations of upcoding and be able to justify every level 4 code you report.

Torrey Kim, Contributing Writer, Raleigh, North Carolina