Wiki Established Pt Visits

[jifnif]

I understand E/M and I code for three different facilities. I know that established pt's only need 2 of 3 components. Here is my question: for a pt that is low or moderate MDM but the physician does a comprehensive history and a comprehensive exam would you consider that a 99215? I was under the impression that the pt's level of sickness or the MDM was a factor that pretty much was always one of the 2 out of the 3. Seems like it would be pretty crazy to put a lot of work into a pt that is only of low complexity and get a high paying code, like maybe fraudulent? Just want to clarify if there is a guideline that I have overlooked. Thanks.

 

[Walker22]

A situation like this (where a high level of history and exam for a low level complaint) might technically qualify for a 99215. Most insurances, however, would decide that it wasn't medically necessary to do such a high level visit for such an insignificant problem and deny the whole thing.

 

[RebeccaWoodward*]

I understand E/M and I code for three different facilities. I know that established pt's only need 2 of 3 components. Here is my question: for a pt that is low or moderate MDM but the physician does a comprehensive history and a comprehensive exam would you consider that a 99215? I was under the impression that the pt's level of sickness or the MDM was a factor that pretty much was always one of the 2 out of the 3. Seems like it would be pretty crazy to put a lot of work into a pt that is only of low complexity and get a high paying code, like maybe fraudulent? Just want to clarify if there is a guideline that I have overlooked. Thanks.

It may depend on your particular carrier; however, CMS states:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Use of Highest Levels of Evaluation and Management Codes

Contractors must advise physicians that to bill the highest levels of visit codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).

The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history.

The comprehensive examination may be a complete single system exam such as cardiac, respiratory, psychiatric, or a complete multi-system examination.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

 

[dballard2004]

Medical necessity should be the determining factor for the selection of the level of service for an established patient even if the other two key components exceed the level of service for the complexity of the patient encounter.

SOURCE: Medical Record Auditor by Deb Grider, Chapter 7, page 248

 

[jifnif]

Thank you, thank you and thank you! Now again I am faced with how to bring it up to a QA on a new job? I just don't want to lose pay when my auditor is auditing different than I am coding.