Pediatric Coding Alert

Surprise! CPT and CMS require medical necessity for all E/M visits

If you fall for the "E/M loophole" myth, you could miscode your E/M levels and collect thousands more in payment than you are entitled to receive.

Are there pitfalls in coding routine visits (ear infections, sore throats and so on) as level four (99214) instead of level three (99213), provided a physician meets the necessary coding guidelines? asked a pediatrician reader of Pediatric Coding Alert. "My partners have been exploring this as a way to increase revenue," he said.

Let Medical Necessity Steer Code Choice

The E/M guidelines absolutely do not offer physicians a legal "loophole" by allowing them to ignore medical necessity, 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," Levinson says. CPT includes this important contributory factor for every service level that measures care using the three key components.

Also: Physician specialty societies developed and approved CPT's Clinical Examples in Appendix C to illustrate the level of care representative patient problems warrant, Levinson says. The clinical examples "are provided to assist physicians in understanding the meaning of the descriptors and selecting the correct code," according to CPT.

Realize 2 of 3 Creates 'Loophole'

The loophole results from CPT's established patient office visit code descriptors. When reporting 99212-99215, you must meet or exceed two of the three elements for your level of service, says Janet McDiarmid, CMM, CPC, MPC, of St. Petersburg Pediatrics, which has eight offices serving Pinellas County, Fla. "For instance, if your history and examination was a 99214 and the medical decision-making was 99215, your code selection would be 99214."

So would it be appropriate to code 99214 when you take a detailed history and examination (99214) but your medical decision-making is of low complexity (99213)? "Anyone can document enough bullet points to qualify for a 99214 with regard to almost any complaint," says Charles Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey. If you keep asking historical data and keep examining every body part, you will hit the criteria for the 99214 or even a 99215, he says.

Catch: There is a big overriding factor--medical necessity. "If medical necessity is not evident in the documentation, the charge could be downcoded and would be considered abusive behavior," says Suzan Hvizdash, BS, CPC, CPC-EMS, CPC-EDS, physician education specialist at UPMC Presbyterian-Shadyside in Pittsburgh.

Count Relevant History, Exam

 If you're still considering coding uninvolved otitis media (OM) cases using 99214, look at 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 points 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." If a patient presents with ear pain and you perform a neurological examination because you're trained as a doctor to do so, but that exam component isn't relevant to the reason for the encounter, then that examination is not medically necessary, says Richard Tuck, MD, FAAP, medical director of quality care partners for PrimeCare of Southeastern Ohio in Zanesville.

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.

Impact: "A diaper rash can't be construed as a 99214 no matter how much data has been thrown on the chart," Scott says. "If your diagnoses don't seem to match the codes--for instance, 99214's with pharyngitis (462) or otitis media (such as 382.9, OM NOS) as the sole ICD-9 codes--you absolutely will be inviting an audit."

Trigger Audit With Skewed Higher E/Ms

Coding more 99214s could set off a red flag to your insurers. "Local carriers use 'bell curves' or utilization data by specialty to target practices for audits," Schwalm says. "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."

Do this: Judge if your practice could be overcoding--or undercoding--services. Scott says that in his experience, "A general pediatric practice should have a ballpark range of sick visit codes as follows:

• 99212--12 percent
• 99213--50 percent
• 99214--35 percent
• 99215--3 percent."

Think Higher Level With Complication

Having more 99213s than 99214s suggests that most OM and pharyngitis cases will fall into 99213, with more than half of those qualifying for 99214 and a few being level two. How can you tell the difference?

Think of 99213s as your "uncomplicated, straightforward" cases, Tuck says.

Tip: Look at multiple diagnoses as a key indicator of a more involved OM or pharyngitis case. A 99214 should represent a "known condition with a complication or with associated systemic symptoms," Tuck says.

Example: A child comes in with high fever and otalgia. Coding the added complication of high fever (780.6) in addition to the OM diagnosis (such as 382.00,
Acute suppurative otitis media without spontaneous rupture of eardrum) can support a higher-level code (99214). Similarly, if the child has had repeated ear infections and you decide to review past chart notes and then discuss the possibility of ventilating tubes with the parent, you might be into the 99215 realm--especially if you code based on time you spent counseling and/or coordinating care (more than 50 percent of the face-to-face visit time), Tuck says.

Caution: Using multiple ICD-9 codes does not alone support a higher-level E/M; rather, it is the increased history, examination and/or medical decision-making (MDM) that the multiple diagnoses require that increases the code level. See how it works by comparing two vignettes for attention deficit hyperactivity disorder (ADHD) (314.01, Attention deficit disorder of childhood with hyperactivity):

Case 1: A three- to six-month follow-up of a child with ADHD who is doing well using medication and without other problems.

Case 2: Follow-up evaluation of an established patient with ADHD with failure to improve on medication.

This later complication requires more history (past family social history, extended review of systems), additional examination (detailed neuro versus single neuro) and, more important, discussion of possible interventions, upping the MDM from low to moderate. Thus, medical necessity to address the complication requires increased history and examination and involves more MDM, warranting 99214.

Look to Other Areas for A/R Boosts

While many physicians can empathize with doctors who feel they are collecting inadequate payment, "upcoding for the mere sake of increasing revenues is a dangerous practice--and I would highly encourage you to NOT go that route," Scott says. You can increase revenue safely by seeing more patients and by learning to code correctly for all you do.

For concrete tips on more ways to increase your practice's income, see next month's Pediatric Coding Alert on uncovering revenue boosters.