Neurosurgery Coding Alert

Here's why coding 99215 regardless of medical necessity could cost you

Coders, beware: Some physicians believe that when coding E/M services for established patients, there is a loophole that allows level-five reporting regardless of the medical necessity of the encounter. Practices that try to exploit this loophole myth could be severely miscoding E/M levels.

Common misconception: Some physicians interpret E/M rules to mean that they can report a level-five E/M based on history and examination if they can substantiate in the record that they performed a comprehensive history and examination on this patient -- even though the medical decision-making (MDM) is low complexity.

Therefore, the physician thinks she is entitled to bill 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; medical decision-making of high complexity) for any E/M visits during which she performs a comprehensive physical and exam, even if she treats a patient with a mild headache.

So the question is: Do the E/M guidelines offer physicians a legal -loophole- by allowing them to ignore medical necessity?

-Absolutely not,- says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care.

-CMS indicates in its Carriers- Manual that -Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code.-  The nature of the presenting problem is CPT's measure of medical necessity for E/M services, and this factor is included for every level and every type of service that measures care using the three key components,- he says.

Explore the Origins of This -Loophole-

Some coders may wonder why physicians use what could be called a loophole. -It's not really a loophole as much as it is a code definition,- says Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician education specialist for the department of surgery UPMC Presbyterian-Shadyside in Pittsburgh. -In CPT it says that on established patients, only two out of the three components need to be met in order to code the service. However, there is a big overriding factor -- medical necessity.

-If medical necessity is not evident in the documentation,- Hvizdash says, -the charge could be downcoded and would be considered abusive behavior.-

So when would the neurosurgeon perform comprehensive history and exam without sufficient medical necessity for 99215? -It could be that the patient came in for a chronic and self-limiting diagnosis; it could also be a case where the physician felt as if he was performing a service of high complexity, but did not dictate all of the indications in detail,- says Margaret Mize, CPC, coder at Birmingham Neurosurgery & Spine Group in Alabama.

Consider this example, courtesy of Mize: An established patient reports complaining of back pain from overworking. The physician orders an MRI and lumbar blocks -- though the patient did not have any type of radiculopathy or other associated symptoms to meet medical necessity for the MRI -- and recommends an over-the-counter anti-inflammatory, such as ibuprofen. Further, the patient has not had any conservative treatment.

In this instance, medical necessity does not justify the MRI, so the MDM would be low. Even though history and exam would otherwise make it a level-five service, the nature of the presenting problem dictates that you cannot code the service above level three. On the claim:

- report 99213 (... an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M.

- link ICD-9 code 724.2 (Lumbago) to 99213 to represent the patient's back pain.

Pay Attention to Time on E/M Claims

In addition, you should consider the amount of time that CPT suggests for billing 99215. CPT states that 99215 encounters normally require at least 40 minutes of physician time, and this is the determinative factor if counseling or coordination of care make up more than half of the visit. So in the example above, code 99215 could be justified if the patient had numerous questions and required extensive counseling. However, most physicians are not spending this kind of time treating presenting problems that are self-limited, minor, or of low severity.
 
Consider this example, also from Mize, as a scenario that meets all the requirements for level-five reporting:

A patient reports with headache, visual disturbances with some loss of peripheral vision, and abnormal lab values. The surgeon finds a pituitary adenoma that is now increasing in size with worsening symptoms. The surgeon pinpoints four elements of the history of present illness (HPI) and performs a comprehensive exam of eight or more systems to determine what else the adenoma could be affecting.

The surgeon recommends complete pituitary panel, complete ophthalmological exam with visual fields, medications and surgery planning for transsphenoidal hypophysectomy with an ear, nose and throat doctor as co-surgeon. The surgery is not without risks to the patient, who is upset about the findings. The physician then spends an additional 25 minutes (out of a total of 45) explaining what damage this tumor could cause and going over the risks of the surgery with the patient.

In this scenario, the neurosurgeon met history, exam and medical-necessity requirements for a level-five E/M. On the claim:

- report 99215 for the E/M.

- link 227.3 (Benign neoplasm of other endocrine glands and related structures; pituitary gland and craniopharyngeal duct [pouch]) to 99215 to represent the patient's adenoma.

- link 368.9 (Unspecified visual disturbance) to 99215 to represent the patient's visual symptoms.

- link 784.0 (Headache) to 99215 to represent the patient's headache.

History Must be Relevant to Presenting Problem

If your neurosurgeon still balks at coding simple, uninvolved E/M services using 99212 (... a problem- focused history; a problem-focused examination; straightforward medical decision-making) or 99213, refer him to the E/M documentation guidelines, which make several references to medical necessity, says Erica D. Schwalm, CPC-GSS, CMRS, billing and coding educator in Springfield, Mass. Schwalm refers to the following references from the 1995 E/M Guidelines:

Page 2: -The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.-

-The key word here is -relevant,- - Schwalm says. If the patient presented with a mild headache, a comprehensive history and exam would not be relevant to the reason for the encounter.

Page 10: -The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).-

-The clear message here is that the history, exam, and medical decision-making performed should correlate with the presenting problem(s),- Schwalm says.

Learn How Insurers ID Red Flags

If your physician bills all 99214s and 99215s, -you could set off a -red flag- to your insurer, not to mention the complaints you will get from your patients, which could also hurt your bottom line in the long run,- Schwalm says.

-Local carriers use -bell curves- or utilization data by specialty to target practices for audits. If you start billing out a majority of your E/M services at higher levels, your utilization data will be well above what is considered the norm, which could make you a target for an audit,-  Schwalm says. And remember that an auditor will look at the E/M services against the medical necessity, so your documentation will have to speak for itself. If it doesn-t, you could be in trouble.