Wiki Outpatient E/M level of service

[saralynnadams@gmail.com]

Hi! Coding for an outpatient hospital BMT clinic. The providers are expecting the vast majority of notes to be coded at level 5s. Most of these patients are on chemo or being monitored for toxicity from chemo. Those are falling in the high risk category but the providers are having a hard time grasping that they also need to meet a high level in either problems addressed or data as well. They are expecting that just because a pt has cancer, the problem addressed is high. For example, a pt with AML in remission and stable but on maintenance chemo with moderate data is being coded 99214. They do not agree. I have suggested they use more descriptive words when describing the status of the conditions and side effects (stable, severe, profound, etc). Does anyone else run into this issue or have any suggestions on how to better educate the providers?

 

[csperoni]

Yes, some physicians who work with cancer patients automatically feel that just because the patient has cancer, everything is the highest level.
I am in the fortunate position that my clinicians document, and my coders code. We educate the providers to ensure they are documenting everything they perform, but beyond that, coding is not their responsibility.
I would show them the 2021 Outpatient AMA guidelines. You must meet 2 of the 3 elements. So besides the high risk, they must have high number and complexity of problems or extensive data.
Certainly, educating about severe exacerbation, progression or side effects is helpful.
From the AMA guidelines:
Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.

For data, regardless of the amount of data, you must also have either independent interpretation of test or discussion with external clinician. Ordering 25 tests without independent interpretation or discussion with external clinician still only gets to moderate data.

The other option to get level 5 is total time spent on the date of service (excluding other billed procedures).

I would agree that your example is 99214 unless the documentation is incorrect.

 

[JJoslin]

Yes, some physicians who work with cancer patients automatically feel that just because the patient has cancer, everything is the highest level.
I am in the fortunate position that my clinicians document, and my coders code. We educate the providers to ensure they are documenting everything they perform, but beyond that, coding is not their responsibility.
I would show them the 2021 Outpatient AMA guidelines. You must meet 2 of the 3 elements. So besides the high risk, they must have high number and complexity of problems or extensive data.
Certainly, educating about severe exacerbation, progression or side effects is helpful.
From the AMA guidelines:
Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.

For data, regardless of the amount of data, you must also have either independent interpretation of test or discussion with external clinician. Ordering 25 tests without independent interpretation or discussion with external clinician still only gets to moderate data.

The other option to get level 5 is total time spent on the date of service (excluding other billed procedures).

I would agree that your example is 99214 unless the documentation is incorrect.

I am having the same issues with my providers, however, many of the patients are inpatient due to the fact that they are either getting chemo or stem cell transplants so they do meet the high level of decision making but I feel that if the patient is stable and levels are stable and the patient is just being monitored it should fall into the level 4 for problems addressed. My providers are not agreeing so I am at a loss also. It is such a fine line with cancer. I think everyone may have a different idea of what to code for that.

 

[sls314]

I am having the same issues with my providers, however, many of the patients are inpatient due to the fact that they are either getting chemo or stem cell transplants so they do meet the high level of decision making but I feel that if the patient is stable and levels are stable and the patient is just being monitored it should fall into the level 4 for problems addressed. My providers are not agreeing so I am at a loss also. It is such a fine line with cancer. I think everyone may have a different idea of what to code for that.

It may help to look at the utilization curve by specialty. CMS publishes Part B E/M utilization data by specialty. You can look at the raw data on the CMS website, but the AAPC website also has a free tool that uses the CMS Part B data to generate a bar graph too.

The CMS data can be found here - scroll down to the Related Links section. The most current raw data file is named "CY 2021 Evaluation and Management (E&M) Codes by Specialty."

The AAPC look up tool which puts that CMS data into a searchable bar graph can be found here:

https://www.aapc.com/tools/em_utilization.aspx

Many specialists assume that their levels should automatically be at the highest level, simply because they are specialists. Showing them a comparison of their utilization against the national averages for other physicians of the same specialty could get their attention.

For Hematology/Oncology, you'll see that for established patients 55.4% of visits were billed at a Level 4. Only 14.7% of Hematology/Oncology established patient visits were billed at a Level 5.

If your providers are billing most of their established patient visits at a Level 5, they will stick out like a sore thumb and be a red flag for an audit.

If their documentation supports what your providers are billing, then they won't have anything to worry about on an audit. Maybe they are a statistical anomaly compared to other hematology/oncology providers.

However, I suspect that an audit might not go in their favor, considering that you're familiar with their documentation and are questioning their E/M levels.

 

[sls314]

New patient Hematology/Oncology E&M utilization does skew more towards the higher levels, which makes sense for all the work and MDM involved in assessing a new patient.

51.2% of new patient visits were billed to Medicare at a Level 5, and 38.1% were at a Level 4.

These utilization curves are just a comparison tool to see where they stand compared to the average of others in the same specialty.

It's not necessarily "bad" to be statistically off the E/M utilization - practices have different patient mixes, and someone's bound to be above and/or below average. The key is being able to back it up and know that the documentation supports whatever levels the practice is billing.

 

[JJoslin]

It may help to look at the utilization curve by specialty. CMS publishes Part B E/M utilization data by specialty. You can look at the raw data on the CMS website, but the AAPC website also has a free tool that uses the CMS Part B data to generate a bar graph too.

The CMS data can be found here - scroll down to the Related Links section. The most current raw data file is named "CY 2021 Evaluation and Management (E&M) Codes by Specialty."

The AAPC look up tool which puts that CMS data into a searchable bar graph can be found here:

https://www.aapc.com/tools/em_utilization.aspx

Many specialists assume that their levels should automatically be at the highest level, simply because they are specialists. Showing them a comparison of their utilization against the national averages for other physicians of the same specialty could get their attention.

For Hematology/Oncology, you'll see that for established patients 55.4% of visits were billed at a Level 4. Only 14.7% of Hematology/Oncology established patient visits were billed at a Level 5.

If your providers are billing most of their established patient visits at a Level 5, they will stick out like a sore thumb and be a red flag for an audit.

If their documentation supports what your providers are billing, then they won't have anything to worry about on an audit. Maybe they are a statistical anomaly compared to other hematology/oncology providers.

However, I suspect that an audit might not go in their favor, considering that you're familiar with their documentation and are questioning their E/M levels.

Wow, thank you so much for all this useful information. Since it is clear you really know your stuff, do you have any advise on how to get some specialized training in the Hem/Onc field besides taking the certification class which I feel is kind of basic? I am looking for tip sheets, learning materials, etc if you have any ideas. Thank you in advance.