Neurosurgery Coding Alert

Question: We recently performed an internal audit and found that one coder was reporting 99213 in several cases when the documentation warranted 99214 or 99215. When we brought it up, she said she thought the physician documented enough for 99214, but she wasn’t sure, so she reported 99213 to stay on the safe side. What can we do to avoid this in the future?

Texas Subscriber

Answer: If the coders are assigning the levels of service, they should be using an auditing tool. There are many auditing tools available, including the ones that the payers use and make available on the web. Coders should never “think” the physician documented one way or another: they should know. And then if the documentation and the medical appropriateness of the code is there, it should be billed that way.

When you’re assigning evaluation and management (E/M) levels, you can’t afford to miss any of the elements of history, medical decision making, or exam. The history, especially on an established patient, is usually the portion of the visit that is not always thorough. However, depending on the payers’ interpretation, the exam might not be documented well. There is a difference between an expanded problem-focused exam and a detailed exam.

The payers may have different rules on this. One payer may say that two-to-seven body areas or organ systems with at least one system being more detailed should count as a detailed visit, while another payer says that at least four organ systems should have four descriptors under each one.

Coding tip: Coders should have in writing the E/M definitions of their top payers so they can identify when a 99213 was accurately documented.