Medicare Compliance & Reimbursement

Beware of vague guidance from CMS regarding this code.

You can't rely on the number of organ systems or body areas to figure out if your evaluation & management (E/M) visits with established patients meet the requirements for a 99214.

But don't panic: You can bill the 99214s you deserve, if you pay attention to your doctor's documentation and the guidelines from the Centers for Medicare & Medicaid Services (CMS)
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What CMS says: The actual written guidance from CMS is "extremely vague," says Catherine Brink, president of HealthCare Resource Management in Spring Lake, NJ. CMS will never publish, in actual numbers, how many organ systems or body areas the doctor needs to examine for a 99214.

But CMS does say you need a "detailed" examination for a 99214, versus an "expanded problem-focused" examination for a 99213. An expanded problem-focused exam is a "limited examination of the affected body area(s) or organ system(s) and any other symptomatic or related" areas or systems.

Take note: Meanwhile, CMS defines a detailed examination as "an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ system(s)." In other words, the doctor needs to examine the affected area or system, plus at least one other area.

The only difference between physical exams for 99213 and 99214 is that one is "limited" and the other is "extended," according to the CMS guidelines. Your physician can review two to seven areas or systems for either code. What's different is how much detail the doctor goes into about each area or system.

Do this: "You cannot just make very short single statements and say that's a detailed exam," says Brink. "You have to say in more detail more specific things about the affected body area or organ system."

For example: A patient has a heart problem, including high blood pressure and hypertension. If the doctor simply says something like, "heart has regular rate and rhythm," that's not a detailed examination. But if the doctor notes the patient's S-wave, T-wave, lack of clubbing and lack of regular gallops or rubs, that's more detailed, says Brink. The doctor also checks for clubbing or edema in the lower extremities and pedal pulses, and also checks the pulmonary area.

In that case, the doctor could also examine other areas, such as the gastrointestinal tract, but an auditor probably wouldn't take them into account because the patient has no problems in those other areas.

"Limited" versus "detailed" exams remain a subjective difference that leaves "a lot of discretion to the auditor," notes Brink. "I could look at it and say, 'That looks like a detailed exam to me,' and another auditor could say, 'I don't think so.'"

Caution: But you shouldn't assume that just because you have five or more body areas or organ systems, that you have a 99214, experts warn. "A physician can document five organ systems and make a brief comment on each organ system, and Medicare will disallow it because it lacked a more extensive/detailed exam of the affected organ system," says Mary Falbo, president of Millennium Consulting in Lansdale, PA.

Tip: Newbie coders should compare their physician's documentation to the 1997 guidelines -- instead of the 1995 guidelines -- to see how close the documentation comes to a detailed exam, says Stephanie Jones, chief auditing officer and VP of operations with Parses Inc. in Tampa, FL.

Rule of thumb: Usually, once the coder finds more than six or seven "elements" in a particular organ system, the doctor has done a detailed exam, says Dennis Mihale, CEO and medical director of Parses, which makes the Codexact medical record review system.