Wiki 99213 vs 99214 - We have had a lot of discussion

[cindygtchc]

We have had a lot of discussion on getting a 99214 with a simple acute problem. For instance, if a patient comes in for an ear infection. This is a new problem with a prescription so in the decision making section this would make it a 99214 and then if you have 4 elements in the HPI and 2 ROS and 1 PFSH, the History section would warrant a 99214. Giving this information above, would warrant the entire visit for a 99214, However some Insurances will not consider this a 99214 and instead will downcode to a 99213. How should I explain to the providers what is right and wrong. Their dictation actually warrants the 99214 but an ear infection is a somewhat simple problem to diagnose so I can see where the confusion is. Any input would be greatly appreciated.

 

[cheermom68]

The nature of the presenting problem/medical necessity should drive the code selection. Does a simple ear infection for a normally healthy patient warrant a 99214, probably not. You could have a comprehensive history and exam for a simple cold but that wouldn't make it a 99215. Our contractor stated that you should always start your code selection with the nature of the presenting problem/medical necessity and work backwards. If the problem starts at a 99214 but the documentation is only there for a 99213, then 99213 it is, however if the problem starts at a 99214 and the documentation is there for a 99215, it can still only be a 99214.

 

[MikeEnos]

I agree, you can't just take every new problem that warrants a prescription and call it a level 4. Some new problems are minor (only worth 1 point in MDM-A) and others don't warrant a detailed history or exam. For example, if a 6 year old goes to the pediatrician with new onset of otitis media, which warrants antibiotics, that's not typically a 99214. The medical decision making in that case is Low, so it really only warrants a 99213.