Wiki Guidelines to meet 99215

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AngelaMehl

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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. :eek: 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. :mad: 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.
 
The level of History, Exam and MDM must be Medically necessary based on the presenting problems. One example would be a splinter in the finger. You could do a comprehensive History and Exam but the information gathered would be completely useless in diagnosing and treating a splinter. There is a good article about Medical necessity vs MDM in the October AAPC magazine.
 
I generally quote directly from the documentation guidelines issued by the AMA/CMS (1995 or 1997 whichever is most appropriate). I have also given the providers a copy of the audit sheet that is used when reviewing their notes. Also, if you have documentation guidance from your biggest payers that can help support your arguments. The providers may not like the documentation guidelines, but they are what counts if you want to get paid and avoid economic consequences from outside audits.
 
If there is an argument, or anticipated argument, I will complete an audit sheet on the chart. Then, I will print the patient's chart and write all over it (highlight portions that need more information, and specify what is missing to meet a certain level of service).

Do you have a specific audit tool that you can show the provider?
 
CMS defines the office visit code 99215 as ?OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PHYSICIANS, OTHER QUALIFIED HEALTH CARE PROFESSIONALS, OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. TYPICALLY, 40 MINUTES ARE SPENT FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY.

https://www.cms.gov/medicare-covera...32007&Group=1&RangeStart=99211&RangeEnd=99215
 
He probably knows he shouldn't be doing it but he's just being difficult. I'd take a simple approach and just give him a copy of the table of risk and highlight the "high" column and explain that those are the types of problems and/or treatments that he needs to be doing to bill a level 5.

Then when he understands that, explain the rest of what's needed for a level 5.

If that doesn't help him, nothing will. He's just being unreasonable and he'll get caught.

Good Luck!
 
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