Wiki Advice on 99214s

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KaylaRieken

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Our providers always document a comprehensive HPI and Exam on every patient no matter what the medical decision making is going to be. They have asked me in the past why they are not getting 99214s since they only need to get 2 out of the 3. I have told them because it is not medically necessary to document these based on their medical necessity. I know this is going to be brought up again and I was wondering if anyone has any solid documentation that I can bring to my next coding meeting with me.
 
While it is true that E&M levels should be supported by medical necessity, deciding what elements are or are not medically necessary can be challenging and there are no clear published guidelines or detailed documentation that I know of as to how this should be done. Generally, it takes a clinical background to know how extensive a history and exam are required for a given presenting problem, and this is something that takes years to learn and is not within the scope of coding training.

The providers are correct that 2 out of the key components meet the requirements for an established patient E&M code. So if you are not assigning codes based on these CPT guidelines, what process are you currently following for this - how are you currently making the determination that their documentation does not meet medical necessity requirements for a 99214? Does your office not have a policy that you can refer them to?
 
I have only been coding here for a couple years now. The other coder 20 years and the one that retired ( I took her position) she was here for about 20 too). They base it on the medical decision making. (I asked the same question when I started working here too about the 2 out of the 3) It has been alot easier for them to do this lately, as we started with a new EMR in the past year and a half. But with every patient they are dictating a comprehensive HPI and Exam.
 
KaylaRieken said:
I have only been coding here for a couple years now. The other coder 20 years and the one that retired ( I took her position) she was here for about 20 too). They base it on the medical decision making. (I asked the same question when I started working here too about the 2 out of the 3) It has been alot easier for them to do this lately, as we started with a new EMR in the past year and a half. But with every patient they are dictating a comprehensive HPI and Exam.
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To me, it wouldn't matter what "labels" the provider uses (i.e. they call their MDM and HPI "comprehensive") -- the information in the note itself determines what level has been met.
 
Sure!

The doctor can say that his exam was comprehensive, but I would not just give him a comprehensive level without reviewing the documentation. If the documentation only supports a problem focused exam then that is the level that I would use no matter what the provider thinks he did.

Hope that clarifies it for you!
 
Oh yes, now I understand what you are saying. Yes I review their work, and they are doing the comprehensive exams and HPI everytime and on every patient. No matter if we seen the patient a week ago, a month ago, three/four months ago, six months ago, or a year ago.
 
Question. What type of provider is this? If your provider is continually documenting a comp HPI and Exam you need be sure there is no risk of cloning from visit to visit.

The question could also be asked, is it necessary to perform a comp Exam again if the patient was just seen the week before? Does this exam effect your MDM for the patients treatment plan. There is a fine line between Medical Necessity and Medical Appropriateness.

Also to note, when a provider uses an Exam template and they are instructed to change the negatives, be sure that that is happening. For example, if a patient is in a wheelchair but the template is built to read "patient can ambulate without difficulty" that would be a red flag.

There is some thought that certain specialists believe that because of their complex specialty they should always be able to bill a higher E&M. They need to be careful of over documenting just for the sake of getting the higher E&M payment. An option for them would be to document time if these visit are always lengthy.
 
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