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Internal Medicine Coding Alert

Want to Earn an Extra $30 in Deserved E/M Payments?

Published on Fri May 14, 2004

Why you should value your internist's medical decision-making

When internal medicine coders don't know how to calculate a patient's risk level, they could be undervaluing the physician's medical decision-making and downcoding E/M visits -- and getting paid $55 a visit, instead of $85.

Expert advice: Coders often misinterpret the level of risk associated with the physician's plan of care, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

You may assume that the physician must meet the criteria for all three categories of risk: presenting problem, procedure(s) ordered, and management option(s) selected. But a single bulleted item, and the item's position in the table, determines the level of risk, she adds.

Warning: Although risk is an important element of medical decision-making, remember that you should also consider both the internist's number of diagnoses (or management options) and the amount and/or complexity of data the physician reviews when determining the decision-making level.

And you should follow these requirements, found in the Medicare Carrier's Manual, section 15501.A:

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. 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 should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

Solution: Follow the Medicare Guidelines
 
If you want to select the patient's correct risk of complications, make sure you're following Medicare's Table of Risk. The table has three risk categories, according to Medicare's 1995 E/M guidelines:

  •  the patient's disease
  •  the internist's tests and procedures
  •  the internist's general management of the disease. 
     
    The table has four levels of risk: minimal, low, moderate and high, says Darcy Crabb, a patient account representative for Pulmonary Associates in Sioux City, Iowa. Review the following levels and examples of conditions and treatments that meet Medicare requirements.

    1. Minimal -- Your internist treats a minor problem, such as a cold, Crabb says. As for diagnostic procedures that meet the "minimal" criteria, they include laboratory tests requiring venipuncture, x-rays, urinalysis or ultrasounds. Management options include rest and simple bandages.

    2. Low -- Typically, the patient presents with two or more minor problems, one stable chronic illness, or an acute uncomplicated illness. Diagnostic procedures include superficial needle biopsies, laboratory tests requiring arterial puncture, non-cardiovascular imaging studies such as barium enema, and physiologic tests not under stress. Management options include over-the-counter drugs and minor surgery with no risk factors.

    3. Moderate -- The physician treats one or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systematic symptoms, or an acute complicated injury.

    For instance, a patient may present with diabetes (250.xx) and hypertension (401.x). In this level, diagnostic procedures include physiologic tests under stress, diagnostic endoscopies with no risk factors, deep needle or incisional biopsy, cardiovascular imaging studies with contrast and no risk factors, and obtaining fluid from the body.

    Your management choices include minor surgery with identified risk factors, elective major surgery with no risk factors, and prescription-drug management.

    4. High -- The patient has one or more chronic illnesses with severe exacerbation or progression, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurologic status.

    Diagnostic procedures range from imaging studies with contrast and identified risk factors to cardiac electrophysiological tests. As for management options, consider elective major surgery with risk factors, emergency major surgery, and drug therapy requiring intensive monitoring for toxicity.

    Report 99214 With Higher Risk Levels
     
    Your selection of a risk level should be based on the highest criteria the physician has met.

    Try this: A patient presents with a low-level risk under the Table of Risk's "Presenting Problem(s)" category, such as allergic rhinitis (477.9, Allergic rhinitis; cause unspecified). The internist orders x-rays, which is a minimal level of risk under "Diagnostic Procedure(s) Ordered." But then the physician selects a moderate risk level of "Management Options," such as starting the patient on the allergy-relief drug Flonase.

    In any case, a higher level of risk may affect the medical decision-making complexity and change the E/M code you report.

    Example: If you undervalued the physician's management options (initiating or changing intranasal steroids like Flonase), you may have determined that the visit had a low risk and reported E/M code 99213, which Medicare reimburses at $55. But with the visit having a moderate risk, you may be able to report a higher-level code, such as 99214. Nationally, Medicare pays $85 for the code. In all cases, make sure your documentation supports medical necessity.

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