Pulmonology Coding Alert

Payers differ on body-system exam requirements for 99214

If your summer goal is to submit audit-proof office visit claims, we've got good news for you. Check out the following two frequently asked 99214 and 99215 coding questions and our expert advice to keep your E/M coding--and payments--accurate.

Don't Forget Medical Necessity

Question: The E/M guidelines say that I can bill 99215 based on history and examination if I can substantiate in the record that I performed a comprehensive history and examination on this patient, even if the medical decision-making is low risk and there is no data to review. Nowhere does it say I must justify the code after meeting the criteria. Therefore, I perform comprehensive histories and exams for all of my patients and bill higher-level E/M codes for all of them to collect my rightful reimbursement. Am I correctly interpreting the E/M guidelines?

Answer: No. Some physicians do believe that the E/M guidelines offer them a legal "loophole" by allowing them to ignore medical necessity as long as they perform comprehensive histories and exams. But insurers do not agree.

"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,' " says Stephen R. Levinson, MD, author of the AMA's Practical E/M: Documentation and Coding Solutions for Quality Health Care.

"The nature of the presenting problem is CPT's measure of medical necessity for E/M services," Levinson says, "and this important contributory factor is included for every level of every type of service that measures care using the three key components. And the Clinical Examples in Appendix C of CPT have been developed and approved by our own specialty societies to illustrate the level of care warranted by representative patient problems, and CPT directly tells us that the clinical examples 'are provided to assist physicians in understanding the meaning of the descriptors and selecting the correct code.' "

And contrary to what some physicians believe, the E/M documentation guidelines do 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. For example, if an established patient presented with a sprained toe and no other symptoms, 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.

Examine 2-7 Organ Systems for 99214

Question: I recently read in my carrier's bulletin that I need to examine five to seven organ systems for my physical exam to qualify for a 99214. Is this accurate?

Answer: No. In fact, the 1995 E/M guidelines as interpreted by CMS only call for two to seven organ systems or body areas.

Watch out: This misconception appears to be widespread. At least one Blue Cross/Blue Shield plan has said you need at least five systems or areas for a 99214. And this guidance also appears on the Web sites for the American College of Emergency Physicians.

This is an error that many consultants blame on large public accounting firms, which have been intimidated by a wave of audits of 99214s, for spreading this overly conservative guidance. Therefore, the large CPA firms decided to adopt that rule at one point.

Just because specialty societies or CPA firms may state that you need five systems, this doesn't mean that Medicare or payer audits will follow suit.

Most carriers say you need only two to seven body areas or systems for a 99214, including Medicare Part B carriers Empire (New Jersey, New York), TrailBlazer (Delaware, the District of Columbia, Maryland, Texas, Virginia) and Highmark Medicare Services (Pennsylvania). Because the expanded problem-focused exam also includes two to seven systems, the detailed exam requires an extensive system exam of at least one of these two to seven organ systems.

Watch out: The description of "extensive system exam" is very subjective, which leaves room for a different interpretation by each auditor. Therefore, some carriers have adopted another method.

Example: Highmark has enlisted the "4x4" rule, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "When an 'extensive system exam' is questionable, the auditor can also look for four comments in four systems. This will also be accepted as a 'detailed' exam in the state of Pennsylvania," she says.

Private payers may follow their own guidelines, so you should get those in writing.