Podiatry Coding & Billing Alert

Question: I have a question or rather a verification on E/M coding. When coding 99214 and counting bullets I have always thought that each extremity is a separate bullet. Such as lower extremity PT pulse left and right would be 2 bullet points. Is this correct?

Codify Subscriber

Answer: CPT^® code 99214 (Office or other outpatient visit for the evaluation and management of an established patient requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.)

Generally, a patient is considered to be "established" if the same physician, or any physician in the group practice (or any physician of the same specialty who is billing under the same group number), has seen the patient for a face-to-face service within the past 36 months. There must be at least two of three key components to support the service level. 

Report CPT^® code 99214 if the physician spends 25 minutes of face-to-face time with the patient and/or family. (So it seems time spent is a crucial factor.) The Centers for Medicare & Medicaid Services (CMS) does not specifically 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.

According to 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."  

Anyone can document enough bullet points to qualify for a 99214 with regard to almost any complaint. If you keep asking historical data and keep examining every body part, you will hit the criteria for the 99214 or even a 99215. It has to be justified by medical necessity and/or complexity of medical decision making.

"As per both 1995 and 1997 guidelines, each extremity is a separate bullet. According to the 1995 guidelines, extremity is a body area, whereas the musculoskeletal will be regarded as an organ system, which makes the number of extremities irrelevant," Apoorba Ganguly CPC, CPMA, Manager of Coding Dept., Medfin Billing Services Pvt. Ltd., Kolkata, India, reminds us.