Wiki Interesting situation in a Family Practice

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Peter Davidyock

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Hello Everyone,

I recently came across an interesting situation in a family practice. It seems that inside this multi-physician practice two of the doctors are practicing what essentially can be termed as geriatric medicine.
The patients are all on Medicare and each have multiple chronic conditions.

The oddity I find is that the physician documentation supports the level of care they are providing as well as the level of service they are billing (99214).

Unfortunately during a recent internal benchmark of the practice it was discovered that the e/m distribution was heavily weighted to the level fours. Almost to the exception of everything else.
Abusive? Possibly. When the data was run against a geriatric taxonomy the numbers line up almost perfectly. When run against a family practice taxonomy they are near 100% double the national average for a family practice.

I suspect these physicians are an audit target but looking at there documentation they score level fours all day long. Changing their t-code is not a possibility.

Any thoughts or advice?
The documentation is always extended or complete hpi based on multiple medical problems, the MDM is always moderate based on the number of diagnosis codes being managed at each encounter along with the prescription drug management. Exacerbations sometimes push the risk to high.
Exams continually score detailed even though when they do not there is enough else where (hpi and mdm)
 
Question how many patients per day does each provider see? If the average 99214 is, per the CPT book, suppose to be in the 25 minute face to face with the provider range, then in an 8 hour day each provider can see 19.2 patients per day provided he sees them back to back with no breaks. This is also one of the stats that is looked at.
 
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Yes the volume is high, very high. When run against the AMA typical numbers for time spent they are out of line. I have considered this and I am having a difficult time accepting that 25 minutes of physician time must be spent in order to bill a level four.
Here is why (just indulge me for a moment)
A est pt presents to the clinic for a routine check up. A nurse takes the pt to the exam room where vitals are obtained, meds are reconciled, a ROS is completed and the PFSH is inquired upon and updated if necessary. That may take 7 minutes.

The physician comes in (with a scribe) to see the pt.

The ROS and PFSH are reviewed. How long can that take? A minute? 3 minutes if he is going to elaborate on anything?

The physician queries the pt:
Mr Smith how are you tolerating the thyroid medication? Have you noticed any changes since your last visit? Are you still feeling tired? No? Awesome. And how about your chronic back pain? You're doing well with your current medication and exercise routine? Yes? Great. And how about your AFIB? Any chest tightness or problems breathing? You're tolerating the Pradaxa? Let's listen to your heart. Any bruising? Any trouble with your diet regime?No? You are adhering to it are'nt you? Wonderful. How's your blood sugar been? You have not had any issues? Your home testing is going well? No? What seems to be the problem with the home testing? Still tolerating the medication? Great.

Well Mr Smith it appears that everything is going accordingly. You are due to have a PT today. My nurse will call you if we need to adjust your Pradaxa and I will see you back here in 3 months.
The physician leaves the room. He will review the PT when it's completed and he may or may not order labs prior to the next visit.

As he is walking out of the room he begins talking to his scribe:
HPI (something like) The patient presents today for follow up on his stable diabetes, medication controlled afib, medication controlled ddd and medication controlled hypothyroidism. All stable. We will not adjust any medications at this time.

How long did that take? Maybe 10 minutes? That is stretching it. I think more like 6 to 7.
The physician tells his nurse to refill yada yada and blahblahblah, let the pt know to continue the current regimine and schedule the pt back in 3 months. That takes a minute or less.

The nurse, who has been prepping the next pt returns and and hands him off to the in house lab who will ultimately release him.


Ok now, not counting the time this pt sat alone in the exam room he was engaged by the clinical staff for anywhere between 13 to 15 or 17 minutes. Plus the lab time.
The status of four chronic conditions have been established, automatically a comprehensive HPI. One required element met. Established problem to examiner = 4/number of dx for moderate MDM met. 2 or more stable chronic illnesses (we have 4) moderate risk met. MDM Complexity requires 2 or 3 in any column. We have 2 in Moderate.

Right now as it stands we have a comprehensive HPI based on the status of 3 or more chronic conditions (allowed now for the 95 guidelines) and Moderate Complexity MDM. 2 of 3 met or exceeded to assign a level for the visit.
This is a 99214 according to the documentation and it took nowhere near 25 minutes of clinical time.

Now, if I eliminate the e/m for the PT related AFIB I still have 3 chronic conditions which would still meet the requirements for a level four.

Here comes a fly in the ointment. Imagine if you will a NPP with her own scribe and her own nurse performing this exact same visit in the exact same way and time frame. That effectively doubles this physicans production rate for level four visits.

How many can they do in an hr? 3? 4?....each?
Easily.
Let's say 3 each. That's 6 an hour. Times 25 minutes for the AMA time standard equals 150 minutes or 2.5 hrs. Not possible.
If we use the high end of physician/NPP time in the room (10 minutes) we have the physician/NPP engaged with pts for a half an hour every hour.

That's the dilemma for this practice. In an 8 hr day this physicians NPI is billing 48 level fours give or take. 24 for the physician and 24 for the PA (3 an hr each). Not every day mind you. But often enough. According to the time guidelines the max would be 19 or 2.5 per hour. I'm using 3 per hr in my example and I still have a half an hr available every hr.

I'd like some thoughts on this that may possibly go beyond the "That's too many visits according to the time guidelines" stance. What about medical necessity? Would it be appropriate to discharge these patients from the practice and send them to a geriatric practitioner? I do not believe so.

Like I said in the beginning the numbers are a concern. The documentation meets the guidelines. I do not think that the AMA 25 minutes can be taken at face value anymore with the allowed addition of the status of 3 or more chronic conditions.

I keep coming back to the medical necessity of the MDM.
 
Just because a provider can meet the documentation requirements for a particular level does not necessarily mean the visit can be billed out to that level. Medical necessity drives the visit level, not documentation points. Just because a point CAN be documented does not mean that it SHOULD be documented given the reason for the encounter, and just because it was checked as done does not mean it gets counted. And I agree that a level 4 should have approximately 25 minutes of face to face provider time for that level of medical necessity. The problem is that providers have been led to believe that if they use a templet and check this box and this box and so on that the visit can be billed at that high of a level of care and that just is not true. Remember severity of illness must match the intensity of service provided. That is why a high level of care like the 99214 has 25 minutes as an average amount of provider time assigned. This represents a very intensive encounter for a patient with a high complexity of issues, it SHOULD take that long. If it does not then I argue that it is not a true 99214 every time. But when you are talking 3 patients per hour then there is no time for breaks or phone calls or any counseling or anything else if they are all being represented as 99214. I would bet that they all are not really and some should be level 2 and some 3 and so on. It would be more realistic.
I disagree that your example is a 99214, I see no exam performed by the provider, only a review of the ROS, the PFSH must be reviewed and updated by the provider, I did not see where the provider did that, the HPI looks brief to me so I fail to see where the history is anything other than focused. Looks like a 99212 to me. Since HPI is the patients view of the presenting issue I don't feel the provider simple stating these conditions are controlled is what the guidelines have in mind.
 
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Thanks Deb,

First let me say that I am not talking about randomly picking data points to score an e/m level in an EHR.

The status of three or more chronic conditions is a fact. The patient presented for ongoing management of four. How the physician arrives at the determination of the status may be a strong case to argue here. Since a patient cannot make a medical determination of the status of their condition the physician asks questions designed to elicit responses that will help him determine the status.
That makes the data points in the HPI null and void since those are the patients words. The data points in the ROS and PFSH, although gathered (and I did say reviewed) are also null and void.
The following statement from the AAFP outlines what they believe to be acceptable documentation for the status of three chronic conditions: (and this is all that is required to appear in the HPI (since last August)):
AFIB under excellent control, will check pt today and adjust if necessary
Chronic Back Pain under good control will continue current regimine.
Hypothyroid under excellent control continue current medication
Diabetes under....you get the picture

That is it. That is the requirement for the HPI. That and that alone is all that needs to appear in the pt record. Of course the ROS and the PFSH will be there but they are not used to score anything.

There was one exam element. Cardio. It does not have to appear in a templated exam section of the record. It can be pulled from the questions asked (which remember the scribe is taking down. An exam is not going to be needed to score this visit either (I could get on board here and argue that the physician should be examining the back area as well). I have stated as much to the physicians.

The number of diagnosis or treatment options is 4 and because prescription drugs are involved (whether the script is changed or not) the risk is moderate.
The amount and complexity of the data is low. The MDM is moderate. Medicare has stated that the physician thought process is not to be taken for granted and must be part of each and every e/m. That means that the exam OR the HPI is the other factor for this visit.

I cannot see how you spend 25 minutes of physician time in a visit of this type. I honestly can't.
I do see your point and I agree that medical necessity MUST be the overarching criteria for the visit. Does the continuing management of four chronic conditions meet medical necessity. I am unsure. I am not at all comfortable saying that this "is" a level four based on medical necessity. I understand that point counting is unacceptable to achieve a higher level and I preach that all the time to my physicians, midlevels and nurses. But we are not looking at a visit scored by the old 95 guidelines. A four point review of systems here is just as irrelevant as a 10 point. A single element exam is the same as a detailed when it comes to scoring this.

I am having a really difficult time with this. To the point where I am losing sleep. The intensity of the visit is all a part of the physicians thought process.
Should it take a doctor 25 minutes to reach a decision of whether or not a pts condition is stable?
If we dumb done the MDM to the point that when they decide to continue the current treatment are we undervaluing the doctors thought process?

The times I referenced are just average examples and not based on any measured observations. With the times given the physicians and the midlevels have four hours a day committed to these visits (again just an example) leaving them half a day for other various activities.
 
I understand what you are saying, I am just giving a whole different take on it. CMS states that medical necessity is the overarching criteria. I just do not see a level four intensity here, I am trying every way I can think fir you to justify that this is not a level 4, I personally would not code a follow up with no changes and no exam and no counseling as a level 4.
So let's look at this really critical
The CC is follow up
The HPI you are using the review of 3 chronic conditions
The ROS the provider has indicated 5 systems reviewed
You say the PFSH is reviewed? Or is it just noted from a previous, it must be documented specifically as reviewed and patient indicates no additional information
So based on the ROS at best the history is detailed
The exam is nonexistent
MDM
I go moderate for number of dx reviewed, none for complexity of information, and risk at best is straight forward as there was no medication adjustment and no new meds ordered, just to state continue meds is not prescription management
So I get strait forward for MDM, low complexity if you want to stretch it. So that would give it a 99212 or 99213 level.
I know I do this way different that most but I keep a critical eye on the presenting issue and the amount of importance the provider appeared to give the different issues. There is not a lot of risk here indicated not a lot of complexity, it is a simple straightforward follow up encounter, that is how the provider documented it and that is how I will code it. I know that anyone can squint and hold their tongue just right and point to wording that will allow this to be a 99214, however I can just as easy make it a 99212. It is all in how you chose to see certain issues. I see the wording "continue present meds" and such as low risk , not prescription drug management, as nothing was managed.
 
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