Pulmonology Coding Alert

If you've been downcoding to a level-four office visit or lower just to play it safe, you may be missing out on some well-deserved reimbursement. Facing CMS scrutiny of high-level office visit coding and complicated coding guidelines, many practices shy away from reporting 99215 for physician services to escape possible audits. However, you can avoid this problem by learning some clear-cut rules regarding criteria for high-level E/M visits.

If your physician's services adequately qualify for a higher-level E/M code, it could mean the difference of about $30 or $35 as you move up the scale from a 99213 to a 99215. E/M Level Takes Two Out of Three You use three key components to determine the level of E/M service to report. These include the history taken at the time of the visit, the extent of physical examination, and medical decision-making (MDM). For office or other outpatient visits for established patients, you must meet the criteria for two of the three key components to bill for a specific level of care.

Most coders find the MDM piece of the puzzle the hardest to fit into place. Determining the difference between straightforward (S), low (L), moderate (M) and high (H) MDM can be an arduous task. You determine the level of MDM by looking at two of its three categories:
1. Number of possible diagnoses and/or management options
2. Amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed
3. Risk of significant complications, morbidity and/or mortality including co-morbidities associated with the patient's presenting problem(s), diagnostic procedure(s) and/or the possible management options. Unlock Reimbursement With Key Element of 'Risk' Determining the level of risk can be the hardest of the three components because it requires more than just counting diagnosis options or lab tests ordered. According to Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J., this category includes risks associated with the presenting problems, the diagnostic procedures, and the possible management options. The highest level of risk in any of these areas determines the overall risk. Take the four levels of risk as examples:

Minimal One minor problem. Diagnostic procedures include laboratory tests requiring venipuncture, x-rays, urinalysis, or ultrasounds. Management options include rest and simple bandages.

Low Two or more minor problems, one stable chronic illness or an acute uncomplicated illness. Diagnostic procedures include superficial needle biopsies, laboratory tests requiring arterial puncture, non-cardiovascular imaging studies such as barium enema, and physiologic tests not under stress. Management options include over-the-counter drugs, minor surgery with no risk factors, therapy, and IV fluids without additives.

Moderate One or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, [...]