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Otolaryngology Coding Alert

2 Components Don't Necessarily Justify Billing 99215

Published on Wed Feb 02, 2005

Better way: Let the problem drive your E/M code selection

When claiming 99215 based on a comprehensive history and examination, make sure medical necessity underlies these components - otherwise, you could be gaming the system.

Medical Necessity Should Dictate the History

When you determine a visit's history, the type - problem-focused, expanded problem-focused, detailed, comprehensive - that the otolaryngologist claims must be medically necessary based on the encounter. "The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s)," states CPT's E/M guidelines' section "Instructions for Selecting a Level of E/M Service".

Even though a nurse may take the information necessary to support a comprehensive history, the physician's clinical judgment and the patient's problem should determine the amount necessary. "There's certainly nothing wrong with obtaining a comprehensive history," says Hayes H. Wanamaker, MD, an otolaryngologist at Central New York Ear, Nose & Throat Consultants in Syracuse. But always doing so may not be the best use of your staff's time.

Why: Taking a high level of history can be time-consuming. It's probably not worth the time it takes to obtain a comprehensive history unless the patient or problem are complex, Wanamaker says.

Example: An ENT sees an established patient for cerumen removal. In this case, little medical need exists to take a comprehensive history, Wanamaker says.

In fact, claiming a comprehensive history for such a simple problem could be unethical. "Payers and auditors may view such conduct as 'gaming the system' - obtaining a higher-level component than medically necessary just to charge a higher-level E/M service," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.

Bottom line: "Routinely claiming a comprehensive history for a simple problem makes otolaryngologists look unprofessional," Wanamaker says.

Exam's Extent Depends on Problem

You also have to consider medical necessity when determining the E/M service's exam type - problem- focused, expanded problem-focused, detailed or comprehensive. CPT's instructions on selecting the exam type echo its history component guidelines. "The extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s)," states CPT's E/M guidelines.

Translation: A physician's decision to perform a comprehensive exam should stem from the patient's problem(s). Simple problems don't warrant this component level or the physician's time.

Example: An otolaryngologist performs a comprehensive exam for an established patient's follow-up pressure-equalizing (PE) tube check. Performing and claiming this exam level for such a simple problem is inappropriate, Wanamaker says.

Other examples that may not warrant a comprehensive exam include an established patient visit for:
 

  • cerumen removal
     
  • uncomplicated chronic otitis media (OM) (such as 381.1x, Chronic serous otitis media).

    Taking a comprehensive exam when the patient's problem doesn't warrant this level isn't customer-friendly. "It subjects the patient to a more extensive exam than necessary," Cobuzzi says.
     
    Better method: Allow the patient's problem to drive the examination. "If the patient doesn't have a level-99215 problem, you are wasting your time" performing a comprehensive exam, Wanamaker says.

    MDM, Medical Necessity Are Different Concepts

    To bullet-proof your 99215s (Office or other outpatient visit for the evaluation and management of an established patient ...), stress medical necessity's role in E/M level selection. "Medical necessity always has to come into play," Cobuzzi says. "You shouldn't code 99215 just because the otolaryngologist performs and documents two of the three components." The history and exam have to be medically necessary.

    Problem: Some coders confuse medical necessity and medical decision-making (MDM). "They're not the same thing," Cobuzzi says.

    This myth leads coders to think that MDM must always steer the E/M level. "But you may ethically have a level-five established patient office visit without
    high-complexity MDM," Cobuzzi says.

    Example: You could code 99215 for an established patient who has diabetes (250.xx, Diabetes mellitus) and chronic fungal sinusitis (117.9, Other and unspecified mycoses). Even though the case may involve only moderate to high risk and straightforward medical decision-making, medical necessity could justify a high-level service, Cobuzzi says.

    Why: The patient's extensive history with an ongoing problem involving complications makes obtaining a comprehensive history and examination medically necessary. The MDM level, however, is the lowest type - straightforward - because the established problem doesn't require further testing, large amounts of data to be reviewed or involve numerous diagnoses or management options.

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