If you've been downcoding to a level-four office visit or lower just to play it safe, you may be missing out on some well-deserved reimbursement. Facing CMS scrutiny of high-level office visit coding and complicated coding guidelines, many practices shy away from reporting 99215 for physician services to escape possible audits. However, you can avoid this problem by learning some clear-cut rules regarding criteria for high-level E/M visits. E/M Level Takes Two out of Three You use three components to determine the level of E/M service to report. These include the history taken at the time of visit, extent of physical examination, and medical decision-making (MDM). For office or other outpatient visits for established patients, you must meet two of the three criteria to bill for a specific level of care. Unlock Reimbursement With Key Element of 'Risk' Determining the level of risk can be the hardest of the three components because it requires more than just counting diagnosis options or lab tests ordered. Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J., says this category includes risks associated with the presenting problems, the diagnostic procedures, and the management options. The highest level of risk in any of these areas determines the overall risk. Take the four levels of risk as examples: Add Diagnostic Options to the Mix Although determining the level of risk may be the most difficult for you, the number of diagnoses and treatment options should not be overlooked. According to CMS guidelines, the number of possible diagnoses and management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions made by the physician. Document Complexity of Data It is important for the physician to document the tests performed, tests reviewed, and past medical records reviewed, Brink says. If it is not documented, you cannot count it toward the complexity-of-data category of MDM. According to CMS, the amount and complexity of data to be reviewed are based on the types of diagnostic testing ordered and reviewed. The decision to obtain and review old medical records and the discussion of unexpected test results with the physician who performed or interpreted the tests is one indicator of the complexity of data to be reviewed. Clear Up the Confusion With Four Case Studies Considering the myriad information you have to assimilate to determine the level of MDM, you should take a look at the following examples provided by Joel Brill, MD, a gastroenterologist in Phoenix who is the American Gastroenterological Association representative to the CPT Editorial Advisory Committee and RBRVS Update Committee: Putting all of these components together to come up with a level of medical decision-making can be quite a task, so use the chart on page 31 to clear up your coding difficulties.
Assuming your physician's services adequately qualify for a higher-level E/M code, it could mean the difference of about $30 to $35 as you move up the scale from a 99213 to a 99215.
Most coders find the MDM piece of the puzzle the hardest to fit into place. Determining the differences among straightforward (S), low (L), moderate (M), and high (H) MDM can be an arduous task. You determine the level of MDM by looking at three aspects of the visit:
1. Number of possible diagnoses and/or management options
2. Amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed
3. Risk of significant complications, morbidity and/or mortality including comorbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options
You must document an assessment, clinical impression, or diagnosis for each encounter, along with the initiation or change in treatment and any consultations or referrals initiated. For a presenting problem with an established diagnosis, document whether the problem is (1) improved, well controlled, resolving, or resolved or (2) inadequately controlled, worsening, or failing to change as expected. You can use the number and type of diagnostic tests employed as an indicator of the number of possible diagnoses.
The chart uses the method established by the Medical Group Management Association (MGMA) in its E/M Documentation Auditor's Worksheet, which helps quantify the components of MDM. Copies of the complete worksheet can be ordered from MGMA by calling (887) ASKMGMA. More examples of medical decision-making can be found in Appendix C of the CPT Manual. CMS' 1997 guidelines for the documentation of evaluation and management services are available at http://cms.hhs.gov/medlearn/emdoc.asp.