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- Thread starter GretaGrbo
- Start date
SharonCollachi
Guest
My CPT book gives good info in the front. There are three things to remember, once you have all of the elements/levels.
Key Components = History, exam, medical decision-making.
1. For these categories, ALL THREE of the key components must meet or exceed the stated requirements to qualify for the level of E&M service: New patient office, hospital observation services, initial hospital care, office consultations, initial inpatient consultations, emergency department services, initial nursing facility care, new patient domiciliary care, and new patient home.
2. For these categories, TWO OUT OF THREE of the key components must meet or exceed the stated requirements to qualify for the level of E&M service: established patient office, subsequent hospital care, subsequent nursing facility care, established patient domiciliary care, established patient home.
3. When counseling and/or coordination of care is more than 50% of the time spent, then time is the key or controlling factor to choose a level of E&M service (time must be documented).
Now, how does this look in real life? My CPT book has nice charts in the front, but here we go.
1. New patient office: Detailed History, Detailed Exam, (so far, we're looking at a 99203). Now if the MDM is straightforward, we drop down to a 99201 or 99202, because ALL THREE components were not at the level for 99203. If MDM is low, moderate, or high, we get to keep the 99203. We can't get better than that because of the detailed level of the first two key components.
2. Established patient office: Detailed History, Detailed Exam. We're already at a 99214, and since we only need two out of three of the key components, that's what we get, we don't even have to go further. MDM can be any level, again, because it's only 2/3.
3. Established patient office: Doctor spends 30 minutes with patient discussing his diagnosis of (whatever), his treatment options, etc. Doctor does a 15 minute exam. Total time spent in counseling was 30 out of 45 minutes, so time is the controlling factor. That gives us 99215.
Key Components = History, exam, medical decision-making.
1. For these categories, ALL THREE of the key components must meet or exceed the stated requirements to qualify for the level of E&M service: New patient office, hospital observation services, initial hospital care, office consultations, initial inpatient consultations, emergency department services, initial nursing facility care, new patient domiciliary care, and new patient home.
2. For these categories, TWO OUT OF THREE of the key components must meet or exceed the stated requirements to qualify for the level of E&M service: established patient office, subsequent hospital care, subsequent nursing facility care, established patient domiciliary care, established patient home.
3. When counseling and/or coordination of care is more than 50% of the time spent, then time is the key or controlling factor to choose a level of E&M service (time must be documented).
Now, how does this look in real life? My CPT book has nice charts in the front, but here we go.
1. New patient office: Detailed History, Detailed Exam, (so far, we're looking at a 99203). Now if the MDM is straightforward, we drop down to a 99201 or 99202, because ALL THREE components were not at the level for 99203. If MDM is low, moderate, or high, we get to keep the 99203. We can't get better than that because of the detailed level of the first two key components.
2. Established patient office: Detailed History, Detailed Exam. We're already at a 99214, and since we only need two out of three of the key components, that's what we get, we don't even have to go further. MDM can be any level, again, because it's only 2/3.
3. Established patient office: Doctor spends 30 minutes with patient discussing his diagnosis of (whatever), his treatment options, etc. Doctor does a 15 minute exam. Total time spent in counseling was 30 out of 45 minutes, so time is the controlling factor. That gives us 99215.
SharonCollachi
Guest
I forgot to use your example:
Established Outpatient Clinic patient comes in and the results are a Detailed History (99214), Comprehensive Exam (99215), and a Low MDM (99213). Your code is 99214 (you forget about the MDM, and you have two components at 99214 or higher).
Established Outpatient Clinic patient comes in and the results are a Detailed History (99214), Comprehensive Exam (99215), and a Low MDM (99213). Your code is 99214 (you forget about the MDM, and you have two components at 99214 or higher).
GretaGrbo
Guest
On a E/M form that I found online it states: Two out of three elements must be at the SAME level or higher to bill at that level.
So the way that I interpret it you would use the Detailed and Low as you would have to use the same level and one higher? I was also told that you had to include the MDM as one of your calculating elements.
SharonCollachi
Guest
History is level 4, Exam is level 5, MDM is level 3. Two out of three same or higher is 4 and 5, so you bill 4. You're trying to use the lowest two; I'm trying to use the highest two.
For established, you have to use two out of three of the key elements, which are history, exam, and mdm. Unless coding has changed and I'm incorrect, no single element of the three HAS to be included.
Please, if I'm wrong or right, someone else chime in here.
To my knowledge, CMS does not currently require MDM to be 1 of the 3, but they recommend it.
My employer requires us to use MDM as one of the elements. Their rationale was that MDM would be most closely related to medical necessity, which is the overarching criteria.
It all changes in 2021 anyway....
My employer requires us to use MDM as one of the elements. Their rationale was that MDM would be most closely related to medical necessity, which is the overarching criteria.
It all changes in 2021 anyway....
GretaGrbo
Guest
Thank you all so much for the feedback!
GretaGrbo
Guest
I've got another question that goes along with this. If you have a provider that feels the E/M level should be a 3, but the documentation get's you to a 4, is okay to take the judgement of the provider. In my audit I found a clinic that says that the MDM you can interpret and use the judgement of the physician. My experience with coding is that you should bill/code all patients the same .
My answer to whether to use provider's judgment for 99213 or code 99214 is "it depends."
Medical necessity is still the overarching criteria for all of this and certainly open to interpretation. In my opinion, medical necessity and MDM involve some level of medical knowledge and certainly a provider has more medical knowledge than I do.
For an extreme example, established patient comes in with a routine paper cut. Provider documentation is comprehensive hx, comprehensive exam and straightforward MDM. So, if you just state - hx is 5, exam is 5, code 99215, that would be inaccurate.
To me, it depends why the provider thinks this is 99213 and not 99214. More often than not, if a provider comes up with a different level than a coder, it is because the provider is less knowledgeable about coding nuances. They may be using more of a gut instinct rather than the documentation or counting points. If I have a provider who is consistently over/under coding, then we have an education and go over specific examples and documentation. For example, I have heard some cancer docs say "my patient has cancer - everything is level 5 or 4". But a visit to discuss PET results that are normal, with no changes to plan could even be 99212.
I personally go by the coder, unless the clinician can explain by coding rules why it should be different.
Medical necessity is still the overarching criteria for all of this and certainly open to interpretation. In my opinion, medical necessity and MDM involve some level of medical knowledge and certainly a provider has more medical knowledge than I do.
For an extreme example, established patient comes in with a routine paper cut. Provider documentation is comprehensive hx, comprehensive exam and straightforward MDM. So, if you just state - hx is 5, exam is 5, code 99215, that would be inaccurate.
To me, it depends why the provider thinks this is 99213 and not 99214. More often than not, if a provider comes up with a different level than a coder, it is because the provider is less knowledgeable about coding nuances. They may be using more of a gut instinct rather than the documentation or counting points. If I have a provider who is consistently over/under coding, then we have an education and go over specific examples and documentation. For example, I have heard some cancer docs say "my patient has cancer - everything is level 5 or 4". But a visit to discuss PET results that are normal, with no changes to plan could even be 99212.
I personally go by the coder, unless the clinician can explain by coding rules why it should be different.
GretaGrbo
Guest
Thank you, that sounds reasonable.