Wiki overuse 99214

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Same as Ever

The guidelines for using 99214 are the same as they ever were that is based on the 95/7 Guidelines. However CMS as well as the OIG will target the overuse of certain E&M codes. I think the OIG is looking harder at hospital codes this year. However the overuse of any higher level E&M can be an issue and spur an audit. I believe AAPC provides Medicare metrics for 99211-5. So if your doc is using 99214 90% of the time and the metrics are say 50%, that would be a concern and a starting point for a discussion.

Jim S.
 
99214 – Documentation criteria

The documentation must meet the necessary criteria for that specific level of service.
99214 – Documentation criteria
History:
HPI elements: 4 or more
Review of Systems: 2-9 Systems
Past/Family/Social Hx: 1 area

Exam:
1995: Extended exam of the affected body area(s) and other symptomatic or related organ systems (s).OR (2-7 organ systems)
1997: At least two bullets from six organ systems OR 12 bullets from two or more organ systems

Medical Decision Making: Moderate complexity
1. Diagnosis and Management options - Multiple
2. Data Review - Moderate
3. Risk (Refer to table of risk) – Moderate

Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and management service when a lower
level of service is warranted. The volume of documentation should not be the primary
influence upon which a specific level of service is billed. Documentation should support
the level of service reported. The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate medical record.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R178CP.pdf

Here is the AAPC E/M audit tool.
https://www.aapc.com/certification/documents/audit_tool.pdf
 
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Red flags

Other E/M practices that will raise red flags with payers are:
Billing every patient visit at the same level of care
Frequently submitting corrected or amended claims
Splitting claims for the same day of service into multiple claims
When using EHRs, payers will become suspicious if multiple chart entries for office visits carry identical verbiage in the records.

https://www.aapc.com/blog/22545-know-what-your-coding-says-to-your-payers/

Targets of coding and billing audits are chosen largely at random by both public (Medicare and Medicaid) and commercial payers. Nevertheless, physicians can somewhat lower the risk of being audited by avoiding several practices. Chief among those practices is billing the same level of service—usually the “middle” E/M code, 99213—too frequently.

“Sometimes a provider will say, ‘I’ll just pick the middle level, because then I won’t be the target of an audit. But it’s impossible for every patient to require the same level of care, so that’s a big red flag,” says the AAPC’s Jimenez.

Consistently coding at higher levels than other PCPs in your geographic area also is likely to attract the attention of auditors. Maxine Lewis, CMM, CPC, president of Medical Coding Reimbursement Management in Cincinnati, Ohio, notes that computers enable auditors to analyze billing data at a more granular level than before, making it easier to compare physicians with peers in their region, or even their practice, and identify “outliers.”

http://medicaleconomics.modernmedic...content/tags/auditing/cracking-code?page=full
 
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