Urology Coding Alert

E/M codes CPT 99213 and 99214 are very familiar codes for urology coders, and with good reason: Urologists frequently perform office visits that warrant coding at level three or higher. But watch out. You don't want to fall into the trap of reporting a level-three code for every E/M service or upcoding some visits to level four.
 
Follow these expert tips to ensure you choose the right level code every time, knowing when to move up to 99214 and when to stay in the level-three realm.

Get the Scoop on 99214's Requirements

Your first step in choosing the correct code is looking at the differences of the code descriptors for 99213 and 99214:

• 99213--Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers 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 low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

• 99214--... a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers 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. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

To report 99214, your urologist must document at least two of the following: a detailed history, a detailed exam, and medical decision-making (MDM) of moderate complexity.

Remember that to count as a component of your documentation, the history must be pertinent to the patient's current condition, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook. Just because a patient marks on her encounter form that she had skin cancer in the past doesn't mean that you can count that as an additional system review item or an additional diagnosis, unless the condition is pertinent to her urologic diagnosis.

According to CPT, an MDM of moderate complexity requires that the physician meet or exceed two of the following three components:

• multiple diagnoses or management options
• moderate amount and/or complexity of data to be reviewed
• moderate risk of complications and/or morbidity or mortality.

Caution: Automated systems that are set up to document every possible piece of history and examination for every patient will certainly attract the attention of auditors.

Payers and auditors may view obtaining a higher-level component than medically necessary just to charge a higher-level E/M service as "gaming the system," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization in Salt Lake City.

99213 for Every Visit May Send Red Flags

Some insurers put up red flags when a practice only reports 99213 for established patient E/M services, Ferragamo says. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that, he adds.

Bottom line: Choose your E/M code based on the urologist's documentation every time, and your coding will naturally reflect the physician's range of services. The three most common instances that warrant reporting 99214, according to Ferragamo, are:

• An established patient presents with a new problem to the examining physician
• An established patient presents with one chronic (ongoing) or worsening problem and one stable problem
• An established patient presents with three stable chronic or inactive problems/illnesses.