Wiki Frequency of billing high level E&M code

[sdelth4284]

I've searched but have been unable to find any documentation stating how frequently a family practice/internal medicine provider may bill 99214s and 99215s. The question arises with patients over age 65 who have multiple (2-15) chronic conditions.

From a coding perspective the office visits for multiple stable chronic illnesses generally have moderate Medical Decision Making. The providers document a complete ROS and a comprehensive Exam.

If a patient has multiple stable chronic conditions and is seen for 4 visits in a one month time frame, what are acceptable codes and frequency. If the patient has a flare of one or two chronic conditions and the visit is billed as a 99215 is this acceptable with three other 99214 visits?

 

[MikeVee]

As long as the physician has the proper documentation I believe he can bill the codes for whatever he/she does. Is there a legal limit on the amount of times a patient can see the doctor for a follow up office visit?

 

[mitchellde]

There is no limit on the number of encounters , however the number of hours in a workday needs to be relative to the amount of time represented in the visit levels billed in a day. Also the medical necessity needs to support the level of care. While a provide can perform a comprehensive cam, the question is should that level of exam have been performed given the presenting issue(s). Having chronic issues that are stable is not enough to always have a level 5.

 

[sdelth4284]

Right, with EMRs it is very easy to document a complete ROS and comprehensive Exam. With a saved exam template the provider is not changing any information to note all elements are normal.

From an auditing perspective would you accept seven 99214 visits and one 99215 visit in a month and a half timeframe?

One of the issues I see is the separation of acute and chronic issues when the two are unrelated. A patient with chronic illnesses will develop acute issues and schedule visits to be treated for those. It is easy to document that 4-6 chronic unrelated conditions are stable and boost the visit level.

How to convince the provider that submitting eight high level visits can raise the risk of an audit? If there are no standard limits, then how does a payer decide when there are too many? A patient with 6 chronic conditions could see a provider every week for a flare related to one of the conditions and be treated appropriately for just that flare.

 

[thomas7331]

From my experience with auditing visits, payers don't just decide what is too many of a service, rather, they are looking for statistical outliers - they tend to target providers whose billing patterns differ significantly from those of their peers in similar specialties. Once they identify outliers, they may do targeted audits to sample documentation to see if there is a potential problem, and if the samples reveal a problem, then perform a more comprehensive audit.

If your provider's billing patterns are outside of what their peers are billing, that's what will attract scrutiny, not a given number of visits per period of time. If you think that might be the case, I would approach it that way with the provider - not by trying to convince them they're billing to many high levels, but rather asking them to explain why the patients need this level of care, and whether or not they think their peers with similar patients would also need this intensity of service. If the provider can explain this to you, then you have a good starting point to guiding them to putting better detail in the documentation to make it more clear why the level of care is necessary should there be an audit.

Ultimately, though, the documentation will be the best defense. If a patient needs eight visits in a month and a half, the documentation should make that apparent. For that many level four and five visits, I would expect to see documentation of the need for continued management due to such things as abnormal lab tests, symptoms worsening or not responding to treatment, adjustments to medication and/or other changes to the patient's care plan, etc.

 

[sdelth4284]

Thank you. I agree that the patient should have worsening conditions, abnormal labs, or medication changes/management. If the chronic conditions are repeatedly stable I would expect to see lower level visits billed.