Wiki Guidelines to meet 99215

[AngelaMehl]

I am having an issue with one of my physicians who thinks he can bill a level 5 for basically a runny nose and a cough. I have been a certified coder for 12 years and I can review documentation and know just by looking at it whether or not it meets a level 5 office visit. When I talk to one of my physicians, I like to have everything in black and white and I want to make certain that I sound knowledgeable about the issue at hand. Can someone PLEASE give me an example of what to say to him about what criteria he needs to meet for a level 5 office visit? He will write a book in his HPI but barely put enough in his ROS and Exam to meet a level 3. I would like an example of EXACTLY what to say to him for example, how many body systems, what he needs to order as far as labs, x rays, and/or EKG, etc. etc. I don't want any room for him to argue. I want to be able to tell him in the simplest way what he needs in his documentation to meet a 99215. Any help is very much appreciated in advance! I am dealing with a very argumentative and difficult physician. I don't like down coding my physicians, I would LOVE to give him a level 5 but he doesn't understand that it takes a LOT to meet a 99215.

 

[dclark7]

Have you utilized the CMS Evaluation & Management Services Guide? This is published in conjunction with the AMA so he should not be able to argue with the information provided. It's in a PDF format so it's easy to download and save, or to print. https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

What's required is an extended HPI (4 elements), a complete ROS (10 systems) and 2 of 3 PFSH. 95 exam requires 8 organ systems, you cannot use body areas for 99215, 97 has specialty specific guidelines so there are different requirements depending on the specialty. MDM must be High complexity. Documentation isn't the only issue, medical necessity needs to be the first criteria. For most usually healthy people a runny nose and cough is not going to get you a level 5, but if you have an immunocompromised patient with multiple co-morbidities you may possibly get there depending on the documentation and the thought process involved. Hope this is helpful. For established you only need to meet 2 of the 3 requirements, but insurance companies (especially Medicare) are looking at level 5 visits, so the documentation and medical necessity really have to show that the visit warranted a high level of service.

 

[tfeece]

I absolutely agree with Doreen. When you look at the table of risk associated with high medical decision making, you will see examples like abrupt change in neurologic status, acute or chronic illness or injury posing threat to life or bodily function.
While there are other factors in play for the medical decision making as well, I tend to think of level 5's as being a patient where without the physicians immediate intervention, there could be a risk to life or limb.
It can be easy to reach a level 5 on an established patient by providing a comprehensive history and exam. That doesn't necessarily mean though that the comprehensive history and exam were medically necessary. The MDM tends to tell more of the story regarding how sick this patient really is, and showing the medical necessity of providing that high level of history/ exam
I hope this helps.

Terri

 

[AngelaMehl]

Thank you!

Have you utilized the CMS Evaluation & Management Services Guide? This is published in conjunction with the AMA so he should not be able to argue with the information provided. It's in a PDF format so it's easy to download and save, or to print. https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

What's required is an extended HPI (4 elements), a complete ROS (10 systems) and 2 of 3 PFSH. 95 exam requires 8 organ systems, you cannot use body areas for 99215, 97 has specialty specific guidelines so there are different requirements depending on the specialty. MDM must be High complexity. Documentation isn't the only issue, medical necessity needs to be the first criteria. For most usually healthy people a runny nose and cough is not going to get you a level 5, but if you have an immunocompromised patient with multiple co-morbidities you may possibly get there depending on the documentation and the thought process involved. Hope this is helpful. For established you only need to meet 2 of the 3 requirements, but insurance companies (especially Medicare) are looking at level 5 visits, so the documentation and medical necessity really have to show that the visit warranted a high level of service.

Thank you SO MUCH! This is what I needed to see/hear! I appreciate your response!