Wiki Detailed History and Detailed Exam support level 4?

[wynonna]

We have a new provider. She always documents a detailed History and Detailed Exam.
Her view is since she is new she is gathering detailed info on all her patients to get to know them. She usually gives an exam with at least 6 elements since these patients are new to her.
Her Medical Decision Making often has 2 or 3 dx without RX.
I'm often finding low level medical decision making.
Would these office visits be scored as level 3 or 4?
Thank you

 

[Orthocoderpgu]

No a level 4 E/M is not justified simply by having DET Hist & Exam

I have read the 1995 & 1997 GL several times. It became clear to me that when they were written, they did not think that a doc would perform a single component without medical necessity for doing so. I can see them actually thinking this way since the previous codes to E/M really did not have requirements to justify any office visit code billed.

The fact that the provider is just "doing them to get information" on the patient rules out performing them due to medical necessity right now. And I will bet it's the same components being performed on all patients regardless of the reason for their visit. As I have audited different providers in multiple states it's clear that the clinical staff is not using electronic medical records correctly. Almost everyone always has a COMP HIST and at least a DET exam simply because the clinical staff are just filling in boxes in the EMR which leads to this.

CMS states that "Medical Necessity" is the over-arching factor in choosing an E/M code. Note, this is different than MDM. Medical Necessity means anything done "just because we are filling in all the blank spaces our EMR wants us to" are ignored and are not counted in the "Key Components". However, we as coders don't have the skill needed to show which are really medically necessary and which are not.

Your best course of action is to use MDM as the deciding factor in choosing the E/M level. This can be tricky because the only difference between 99203 & 99204 can be one ROS or PFSH since the lowest of the three key components decides the code.

If possible, get your physicians to use the EMR properly and not populate a field (HPI, ROS, PFSH, EXAM" unless they would have documented it BEFORE making the switch to EMR. These days the clinical staff just "fills in all the boxes" in the EMR just because they are there, not because of medial necessity.

 

[Pathos]

A provider should never "pad" their E/M in order to get a higher level. This is Fraud.

Furthermore, a provider should only perform what is medically necessary and reasonable. For example, did you really need to do a Comprehensive Exam on a patient with a Sprained Ankle in order to medically treat this patient? Probably not.

Unfortunately, and as Orthocoderguru is stating, EHR makes upcoding (coding higher than is medically necessary) increasingly easy with just a few clicks here and there. Macros can fill pages and pages of information, which only adds to the volumes of text the next provider has to sift through in order to get to the real details of the patient. Documentation Integrity is key here.

CMS' new Proposal to put Patients over Paperwork, is really cutting into the bone in terms of reducing the required paperwork needed for E/M levels. Unfortunately, this also means reduced reimbursements (and CMS is not know to reimburse a lot already) for providers who bill E/M 4+ on a routine basis (especially specialists). I created a thread on this upcoming Proposed E/M changes in the E/M forum.

To go back to your original question, if the visit should be level 3 or 4. This would depend on the patient status (New vs. Established). If New, then the MDM (Low?) and History and Examination if they all show medical necessity of Detailed History and Exam would make the visit a 99203.
If Established, then the visit could be 99214 (Detailed History and Exam) or 99213 (Detailed History/Exam and MDM) depending on the patient's insurance carrier. Some carriers weigh MDM heavier than the History and Exam components when it comes to Established patient visits.


Hope this is helpful!

 

[wynonna]

A provider should never "pad" their E/M in order to get a higher level. This is Fraud.

Furthermore, a provider should only perform what is medically necessary and reasonable. For example, did you really need to do a Comprehensive Exam on a patient with a Sprained Ankle in order to medically treat this patient? Probably not.

Unfortunately, and as Orthocoderguru is stating, EHR makes upcoding (coding higher than is medically necessary) increasingly easy with just a few clicks here and there. Macros can fill pages and pages of information, which only adds to the volumes of text the next provider has to sift through in order to get to the real details of the patient. Documentation Integrity is key here.

CMS' new Proposal to put Patients over Paperwork, is really cutting into the bone in terms of reducing the required paperwork needed for E/M levels. Unfortunately, this also means reduced reimbursements (and CMS is not know to reimburse a lot already) for providers who bill E/M 4+ on a routine basis (especially specialists). I created a thread on this upcoming Proposed E/M changes in the E/M forum.

To go back to your original question, if the visit should be level 3 or 4. This would depend on the patient status (New vs. Established). If New, then the MDM (Low?) and History and Examination if they all show medical necessity of Detailed History and Exam would make the visit a 99203.
If Established, then the visit could be 99214 (Detailed History and Exam) or 99213 (Detailed History/Exam and MDM) depending on the patient's insurance carrier. Some carriers weigh MDM heavier than the History and Exam components when it comes to Established patient visits.


Hope this is helpful!

Follow up question: Ok. I see both of your points. I respect your answers and I respect the view of the new provider. I understand medical necessity is usually determined by the provider since coders lack the clinical piece. I also understand MDM carries the most weight over History and Exam sections. Also, medical necessity is the overarching theme for the visit, beginning with the chief complaint--reason for the visit-- and HPI and going through the exam and MDM. I just want to present both sides if I decide to go to the practice manager about this (AAPC side and our new providers side). Our new provider has been coding and seeing patients for 6 years at another practice. I know this new provider is NOT copy/pasting from one note to another and she is NOT having staff fill in blanks on EMR or NOR using prepopulated sections. I have gone through several weeks of her notes and her HPI and ROS are different for each patient. The ROS relates directly to chief complaint in each section. The exam is based also on reason for visit. Each of the 3 sections are described in relation to the individual patient and their chronic and acute problems.
The new provider in question is seeing patients who were being treated by 2 other of our providers, who just retired. So every condition is new to this new provider/examiner so she spends more time with her patients (new to her, but established to the practice)
Any advice on how to approach this subject with new provider or practice manager is appreciated. So many visits by this new provider are level 4 History, level 4 Exam, and Level 3 MDM, so I have to address this. I work at home remotely, so my correspondence is usually via email. Thank you for any assistance you may have. I welcome any viewpoint.

 

[wynonna]

I have read the 1995 & 1997 GL several times. It became clear to me that when they were written, they did not think that a doc would perform a single component without medical necessity for doing so. I can see them actually thinking this way since the previous codes to E/M really did not have requirements to justify any office visit code billed.

The fact that the provider is just "doing them to get information" on the patient rules out performing them due to medical necessity right now. And I will bet it's the same components being performed on all patients regardless of the reason for their visit. As I have audited different providers in multiple states it's clear that the clinical staff is not using electronic medical records correctly. Almost everyone always has a COMP HIST and at least a DET exam simply because the clinical staff are just filling in boxes in the EMR which leads to this.

CMS states that "Medical Necessity" is the over-arching factor in choosing an E/M code. Note, this is different than MDM. Medical Necessity means anything done "just because we are filling in all the blank spaces our EMR wants us to" are ignored and are not counted in the "Key Components". However, we as coders don't have the skill needed to show which are really medically necessary and which are not.

Your best course of action is to use MDM as the deciding factor in choosing the E/M level. This can be tricky because the only difference between 99203 & 99204 can be one ROS or PFSH since the lowest of the three key components decides the code.

If possible, get your physicians to use the EMR properly and not populate a field (HPI, ROS, PFSH, EXAM" unless they would have documented it BEFORE making the switch to EMR. These days the clinical staff just "fills in all the boxes" in the EMR just because they are there, not because of medial necessity.

I respect your answers and I respect the view of the new provider. I understand medical necessity is usually determined by the provider since coders lack the clinical piece. I also understand MDM carries the most weight over History and Exam sections. Also, medical necessity is the overarching theme for the visit, beginning with the chief complaint--reason for the visit-- and HPI and going through the exam and MDM. I just want to present both sides if I decide to go to the practice manager about this (AAPC side and our new providers side). Our new provider has been coding and seeing patients for 6 years at another practice. I know this new provider is NOT copy/pasting from one note to another and she is NOT having staff fill in blanks on EMR or NOR using prepopulated sections. I have gone through several weeks of her notes and her HPI and ROS are different for each patient. The ROS relates directly to chief complaint in each section. The exam is based also on reason for visit. Each of the 3 sections are described in relation to the individual patient and their chronic and acute problems.
The new provider in question is seeing patients who were being treated by 2 other of our providers, who just retired. So every condition is new to this new provider/examiner so she spends more time with her patients (new to her, but established to the practice)
Any advice on how to approach this subject with new provider or practice manager is appreciated. So many visits by this new provider are level 4 History, level 4 Exam, and Level 3 MDM, so I have to address this. I work at home remotely, so my correspondence is usually via email. Thank you for any assistance you may have. I welcome any viewpoint.