Wiki "Automatic" level 3

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tamale79

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27
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Pewaukee, WI
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0
Hello,
My boss wants us to charge a 99213 any time a pt gets a med rx or rx to therapy. She said those are automatically level 3s. I told her that MDM is the main driver of the e/m levels, and just b/c a dr writes an rx (or more accurately, the MA enters an order into the computer) does not "automatically" equal a level 3.
Am I wrong??
If I'm correct, does anyone have any documentation specific to rxs that you can point me to?
Thanks
 
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you are not wrong. The only automatic here is, an order for a prescription will give you moderate risk. However MDM is based on two out of three and risk is only one element if the other two elements are minimal then the MDM will come out as straightforward. so you can have I minor diagnosis with no labs ordered or reviewed with a prescription for antibiotics and still have a level 2 visit. your documentation you seek is the 95 or 97 guidelines. These are what we follow for visit levels.
 
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Anyone who claims that they have to bill a specific E/M level every time, is not only setting themselves up for failure; they are coding incorrectly (under or over coding). As a coder you promise to code the encounter based upon documentation, and not by some arbitrary internal office policy that the office needs to churn out a specific code. Not only is this practice unethical, your office is in danger of getting several False Claims thrown at them.

I would be very cautious to follow such a policy, as the office will jeopardize themselves greatly and put themselves at risk for serious allegations. Perhaps a few audits might pass, but this chronic down/overcoding is scary at best. If your boss is still enforcing this practice, I would start updating your resume...

Sources:
OIG
CMS E/M guidelines
 
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Unfortunately, I have seen this response from providers too many times. Perhaps the providers believe they are doing their patients a favor by not billing level 4/5 visits, but in reality they are missing the whole point of medical coding. Apart from missing out on significant revenue (by down/under coding), not coding correctly is in fact a problem. Even CMS has come out and stated that we as coders (and providers) need to code what documentation states. While Up/over coding is probably "worse" than down/under coding, both are still incorrect coding.

Before you storm out of your job, do check in with your compliance officer, and report your concerns with him/her. Do some research from OIG and CMS on what they think about wrong coding, and bring some articles to your compliance officer. Perhaps this might change the compliance officer's mind, and in return change those two providers' mind as well.

Good luck!
 
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tamale79 said:
UPDATE - Two of the drs I work for are demanding that we charge a level 3 for every office visit.
I honestly don't know what to do. Should I report them for fraud? Should I just quit and let it be someone else's problem? Has anyone else ever been in this type of situation??
I would appreciate any opinions/suggestions. Thanks
Click to expand...
Your providers are in no position to 'demand you charge a level 3 for every visit'. Clearly they believe they are above the law and display a 'won't happen to us' mentality' which is unfortunate for you (and probably more so for them). Reporting the same level for every visit is a red flag to any payer because undercoding is as bad as overcoding and I'm thinking your providers don't realize this.
This is a tricky situation and from what you imply, they don't want to hear what you have to say. You can't just report them for fraud however. Surely there is a practice manager you can talk to. It's their responsibility to take this on board.
 
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Try to keep a level head about these things. To the best of my knowledge, no coder or provider has ever gone to jail for incorrect E&M levels. Getting hysterical about this will just exacerbate the situation and make the disagreements all that much harder to resolve.
 
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mitchellde said:
you are not wrong. The only automatic here is, an order for a prescription will give you moderate risk. However MDM is based on two out of three and risk is only one element if the other two elements are minimal then the MDM will come out as straightforward. so you can have I minor diagnosis with no labs ordered or reviewed with a prescription for antibiotics and still have a level 2 visit. your documentation you seek is the 95 or 97 guidelines. These are what we follow for visit levels.
Click to expand...

Agreed. You could also check Appendix C of your CPT manual. One of the examples for 99211 is a patient who lost their prescription and came in for a new one.

It's my opinion (just mine) that if someone says there's a rule for coding they should be able to produce official guidance to that effect. At the very least it will mean the practice will be protected if it is audited and the auditor challenges the claims.

Finally - what if some of those automatic 3s are really 4s?
 
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Thank you both for your help. I've been debating this with her for 5 years, and now she wants to have a meeting to get the providers' input...gee I wonder who they'll agree with??
 
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Just take a copy of the guidelines with you and show how the MDM really drives this and that the documentation is vital. I would take several examples with me. Hope this helps.
 
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UPDATE - Two of the drs I work for are demanding that we charge a level 3 for every office visit.
I honestly don't know what to do. Should I report them for fraud? Should I just quit and let it be someone else's problem? Has anyone else ever been in this type of situation??
I would appreciate any opinions/suggestions. Thanks
 
0
Yeah....we don't have a compliance officer. I can't exaggerate the constant state of chaos that this practice has been operating in for (at least) the last 6 years.

I would also like to clarify that the drs aren't concerned about doing their pts any favors. They just want the extra $35 per office visit that they're missing out on when we charge a level 2. There are NO altruistic reasons involved at all.
 
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You are absolutely correct about their mentality.
My practice manager knows about all of this. According to my billing manager, she (the practice manager) feels that her job is in danger b/c of this. I don't know if the drs have threatened my job or not. They haven't threatened me directly yet.
 
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Do you like these providers enough to go to jail for/with them? I would try one last time to educate everyone involved and if that does not make a difference, walk out the door.

C Collison
 
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Yeah, this is definitely going to end badly. One of the drs in particular is throwing daily tantrums about it, so we're just coding the way they want us to. I have all the emails I've sent explaining why this is a bad idea in a folder titled Audit. Hopefully that's enough to keep me out of jail. I can't force my bosses to follow the rules.
 
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tamale79 said:
Yeah, this is definitely going to end badly. One of the drs in particular is throwing daily tantrums about it, so we're just coding the way they want us to. I have all the emails I've sent explaining why this is a bad idea in a folder titled Audit. Hopefully that's enough to keep me out of jail. I can't force my bosses to follow the rules.
Click to expand...

This is what I would do, although you may have already done this. Go to your direct supervisor or manager and tell her that you take your coding certification very seriously and you cannot be a part of "blanket" coding where you bill out the same level every time. Tell her this is intentional deceit (aka fraud) and is a criminal act which is punishable by fines and/or prison time. I would also offer that you are willing to bill out the ones that are truly 99213s, but that you'll have to turn over the others to her. See if it doesn't open her eyes? A little? And if nothing changes, I would report them to the OIG.

Side Note: Did the guy up there ^really tell you not to get hysterical? :rolleyes:
 
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AC said:
Side Note: Did the guy up there ^really tell you not to get hysterical? :rolleyes:
Click to expand...

Thank you for that! It's 2020, but an angry (for legitimate reasons) woman is still hysterical.

My direct supervisor is the one who has come up with the "policy" for the blanket codes. We have a bunch now. For example, if the pt has a fracture, that's an automatic level 4. Part of their reasoning - at least what they tell me - is that all the big hospital systems in our area are coding level 4 for everything. How they know this, I don't know....and whether it's really for "everything", I seriously doubt. Another part of the new policy is no level 2s ever. The whole thing is just a mess.
 
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There is good news but it's not going to take affect until next year, but 2021 the History and Exam components will be eliminated from the three "Key Components". Next year all E/M will be based on MDM. I have coded several specialties over the years and I think this is more fair to all physicians. With EMR the History is almost always going to be "Comprehensive" simply because the medical staff think they have to check every box in the EMR so the key components now are inaccurate since medical necessity is not met. If you are unable to get them to report E/M correctly, you may need to go work elsewhere. I was in the process of looking for other work when an outside auditing company came in and audited us. I had been going to my supervisors and complaining that the physicians were choosing the incorrect codes constantly. They ignored me until an outside auditing company came in and proved me right. After that, I was given 100% control over the E/M levels that were billed since the company saw that they had a high risk of non-compliance.
 
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