Wiki Level 5 clarification

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kmignault

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I am a relatively new coder/auditor and I have some questions on billing level 5 visits. It's my understanding that these are pretty rare and hard to come across. I have recently been made aware of someone who bills a high amount of level 5s. One way the provider does this is by billing by time. The other way the provider does this is by doing a comprehensive history and exam and reviewing data, ordering labs, etc. to get the data points. I'm not saying this provider is not thorough but I am concerned about the volume of these high dollar charges and I am afraid it may trigger some type of audit or review that would hurt the rest of the providers.

In one instance the patient presented with IBS and I determined the MDM to be moderate complexity. The provider insisted that the patient had SOB, chest pain and these could be potentially life-threatening so it's high risk. In the note there was no indication that the patient was having SOB and chest pain at that visit - rather, it was part of the history that in the past, the patient has exhibited these symptoms. I believe that if it were high risk, the provider would not have referred the patient out, but rather would have sent the patient to the ER. The fact they sent them to another doctor for workup means to me, this is not a life or death problem. Of course SOB and chest pain could be evidence of possible heart and lung diseases, but it could also be just due to anxiety. I don't believe that every patient who ever had SOB and/or chest pain is a high risk patient.

I have been told that this is the way this provider is and all we can do is recommend, but the provider does not have to listen. I don't think this is acceptable. I feel it borders on fraud. I believe if an outside auditor were to come in and scrutinize this provider's charts, it would be a huge mess. I'm not comfortable with this at all, but being so new to my job, I'm really not sure how to handle it.

Am I overreacting? What would you do in this situation? Thank you for your patience, I know this is a long post.
 
Your reaction is understandable if you're new to confronting disagreements over E&M with a provider, but I can assure you this is actually a very common area of conflict between coders and providers and I wouldn't let it get to you. Providers and coders look at documentation in very different ways and providers can often see a level of MDM that coders can't because they can read between the lines and interpret a patient's condition based on their own clinical experience whereas coders must just rely on what is stated clearly in the record. It's true that billing high level visits more frequently that other providers can trigger a payer to do an audit, but payers are most concerned about serious abuse, and I'd reassure you that a difference of opinion between a level 4 and 5 visit based on MDM is not something that typically rises to the level of being fraud.

A couple of things I'd mention:

Regarding level 5 visits - the highest level of MDM may have to be met per coding rules, but this doesn't mean the patient has to be critically ill. Remember that risk is only one element of MDM and as you point out, high MDM can be met in the data and diagnosis points or the level can be achieve by documentation of time. It's true that level 5 visits are for the sickest or most complex patients but it doesn't mean they have to be in a 'life or death' situation or be in need of going to the ER at that moment.

I've seen a lot of audits of level 5 visits by payers. Typically they are looking to see documentation that a patient has a new condition that requires diagnosis, or a condition that is worsening or serious and requiring more intensive treatment, or multiple complex conditions being managed together. The visits that they down-code to a level 4 (assuming documentation supports a 4) are ones where the patient is just being followed and there are no changes being made to the treatment plans.

Since you say you're in an advisory role with this provider, I'd just recommend making your priority to maintain a good relationship with the provider and advise them the best you can. You can let them know why you would have chosen a lower level based on your knowledge of coding and ask them to explain why they chose the higher level. If the documentation meets all of the other requirements, and the provider can give you a reasonable explanation for why this encounter involved high MDM, this is not fraud, it's just a difference of opinion. If you can maintain an open dialogue and avoid confrontation, it has benefits for both parties - the provider learns what coders are looking for and can improve his or her documentation, and it will make you a better coder too as you'll begin to understand what the provider is thinking and become better able to defend your coding choices if needed.

As a last resort, if you continue to disagree and feel that there is real risk in the provider's coding practices, I'd recommend advising the practice to have an external audit done. Having an outside assessment from an expert in the area is often very educational and a more effective way to persuade the providers to make needed changes.

Hope this helps some!
 
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