Internal Medicine Coding Alert

Question: I think my physicians frequently perform office visits that warrant coding at level four or higher for our established patients, but I'm concerned about raising red flags for upcoding. Would you explain how I should determine when I'm justified in billing level four?

• 99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity.

• 99214 -- ... a detailed history; a 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 patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity.

Important: You also need to be sure that the nature of the presenting problem and medical necessity support upcoding to level four.

Caution: Automated systems set up to document every possible piece of history and examination for every patient will certainly attract the attention of auditors.

Potential problem: Some insurers put up red flags when a practice only reports 99213 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.

Bottom line: Choose your E/M code based on the physician's documentation every time, and your coding will naturally reflect the physician's range of services. The three most common instances that warrant reporting 99214 are:

-- Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of government program services for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.