Medical billing CPT 99214 - When and how to use

CPT CODE 99214 -  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 detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers 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, 25 minutes are spent face-to-face with the patient and/or family.


CPT 99214 you are require to meet 2 of the following 3 criteria.

1. A detailed history
2. A detailed examination
3. Medical Decision Making of Moderate Complexity......

Which means, patients with relatively simple conditions that require you to take detailed histories and exams on ARE IN FACT 99214 codes! Unlike as if they were a new patient.... So let's go to how this is judged and review it once again.....

You can look at my post about the 99204 for how new patient visit is judged.....But that level is a little higher than the 99214...... Or maybe we should be more clear the 99214 requires FAR LESS than the 99204....
Huh?

Yes, correct, a 99214 is a lower code than a 99204.....which is why insurance pays less for it.

Not because it is an established patient, but because it is LESS SERVICE!!! FAR LESS SERVICE.

A level 4 established patient is NOT a level 4 new patient.......get the fact that a Level 4 is a Level 4 out of your heads now!!!!


So let's review

1. Detailed History:

Let's examine what the definition of "Detailed" is.
"Detailed History"-Requires a Chief Complaint (CC), "extended" HPI, problem pertinent Review of Systems (ROS) which is "extended" to include a limited review of:

A. Family History
B. Social History
C. Past Medical History

All directly related to patient's problem.....requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems, plus TWO to NINE ROS, plus at least ONE pertinent element of PFSH


Do you remember the HPI Elements? What about the 10 Systems for Review or the PFSHx? If yes, then congratulations. If no, then let's begin.

HPI Elements are:
    1. Location
    2. Quality
    3. Severity
    4. Duration
    5. Timing
    6. Context
    7. Modifying Factors
    8. Associated Signs and Symptoms

There are 2 levels of HPI-Brief and Extended....Most often you are doing an Extended HPI. You essentially have to document 4 of the preceding categories....for ONE problem.

It is as simple as this from EM University: Patient complains of chest pain (location), which began three hours ago (duration). Pain has been off and on since that time with each episode lasting two to three minutes (timing). The pain is described as “crushing” (quality) and at times is rated as an eight on a scale of one to ten (severity). The pain occurs with minimal exertion (context) and is associated with nausea and shortness of breath (associated signs and symptoms). The pain was relieved with sublingual NTG in the ambulance (modifying factors).

This is all you need to do to qualify for Extended HPI, which is wy more often than not, you are doing an extended HPI.


The Review of Systems? Do you remember which they are? In this case we need 2-9 systems, not even the 10 systems......Who does that? Maybe with a hyperacute issue. Which is why you would be billing a level 2-3 for that. The systems, all 14 of them There are fourteen individual systems recognized by the E/M guidelines:

  1. Constitutional (e.g., fever, weight loss)
  2. Eyes
  3. Ears, Nose, Mouth, Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Integumentary (skin and/or breast)
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

There are 3 levels of the ROS

In the case of 99214 you need 2 to 9 systems it is called an "Extended ROS". Whereas the highest ROS is called a Complete ROS.

Why wouldn't you do a complete ROS every time?

Maybe you are pressured to see 20 patients a day and can't provide the highest level of care......

Even better, the staff can do the ROS for you.....Remember that!

Lastly, to meet detailed HPI you have to document one element of pertinent Family/Social/Medical History.

If nothing has changed, you can document no changes since the LAST TIME YOU DOCUMENTED A FULL ROS..........legally that is valid thing to do.

As for PFSH.....do I really have to do this again? You should have been reading the other posts!

There are 2 levels of PFSH, Pertinent and Complete. Pertinent PFSH requires at least ONE in one of the 3 categories-Past Medical, Past Social or Family History. Allergies and Medications are part of Past Medical.2 key points here.



1. A staff member may take the PFSH, thus freeing you up.

2. You ONLY require one medical, one social and one family item to qualify for a "Complete" PFSH, which is probably what you are doing anyways.....



In the 99214 you need a Detailed History, which once again is: The second highest level of history and requires a chief complaint, an extended HPI (four HPIelements OR the status of three chronic or inactive problems plus TWO to NINE ROS, plus at least ONE pertinent element of PFSH .



I think you get my drift.....Your detailed history is ALMOST ALWAYS PERFORMED......Which is why you may be missing your 99214s.

In 2003 Internists used this code only 1/4 of all visits....My guess is that they are actually about half of all visits!


Now onto.....

2. Detailed Examination.



Remember the 1997 rules for examination. Bullets and Systems....that's how it goes...... It is 12 Bullets (Things examined) in ANY ORGAN SYSTEM.....One Bullet for Vitals, One for General Appearance and it is now only 10 bullets in any of the 14 systems. I am not going into those systems. But once again, if you do this and the history, then you are done and you have hit a 99214.......


Lastly, you can get there by one of those 2 and the medical decision making. The 99214 requires Medical Decision Making of Moderate Complexity, just like the 99204.


Which is probably why you confused the level 4 new visit as the same service as the level 4 established visit.....

Which, we now all know, it is not.


Moderate Complexity once again is divided into 3 parts

A. Problem Points
B. Data Points
C. Medical Risk (morbidity and mortality) Remember you need only 2 out of 3 of these targets to meet moderate complexity.



Problem Points-You need 3 points
  • New Problem with work up-4 points
  • New Problem with NO work up-3 points
  • Established Problem, worsening-2 points
  • Established Problem, Stable-1 point

Data Points
  • Independent Review of EKG/Film/Specimen-2 Points
  • Review of Old Records-2 Points
  • Labs/EKG/Film/PFTs Ordered/Reviewed-1 Point
  • Discussion with Physician regarding test-1 Point
Risk?
  • 2 or more stable chronic illnesses-Bingo
  • 1 Chronic Illness with mild exacerbation-Bingo
  • 1 New undiagnosed problem-You have it
  • 1 Complicated Injury-Again, you hit the risk....

How do we define the risk? With a risk table of course......

There you have it! Have you been missing your 99214 codes? I bet you have. 99214 is about 50% of what we are doing! Remember that.



Billing and Coding Guidelines

Billed CPT 99214. Submitted documentation supports down code from 99214 to 99213 with EPF history, no exam, and decision making of low complexity. None of the  required components of 99214 were met. Noted prolonged  visit with patient re: return to work. Time not recorded. Has F18 medical problems, only 2 addressed. Undated problem  list submitted, with 18 problems. Letter to that is referenced in progress note gives brief summary of  condition. 

Established Patient (CPT 99212-99214) – requires two of the three key components 

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99244 to 99214

Pharmacology Visits

Visits billed with CPT code 99214, with or without the addition of a therapy CPT code, require authorization. All visits count against the member’s Behavioral Health and Substance Use Disorder benefit.

Code the EPSDT interperiodic visits (99201-99203 or 99212-99214) with the EP and the 25 modifiers when vaccines are administered during the interperiodic health visit.

Example : Claim is received with service code 99214 and 90863 (with or without modifiers)

Incorrect: These codes are not to be billed by the same provider on the same day. 


Preventive Medicine Visits in Conjunction with an CPT 99214

What should you do when you find a problem during an otherwise preventive medicine visit?

• Select the appropriate preventive medicine code and the E&M code that best represents the problems addressed.

Example

CPT Code Charge


Preventive medicine visit

Established patient, over 65 years old

99397 $225

Office visit, level 4 99214 $175 



Inappropriate use for evaluation and management (E&M) code 99214 - Lead to Audit

Data analysis pertaining to evaluation and management services indicates a high comprehensive error rate testing (CERT) error rate. Current Procedural Terminology (CPT®) code 99214 (Office/outpatient visit, established patient) has been over-utilized compared to other E&M CPT® service codes. Errors identified include inappropriate use of high level E&M CPT® codes that were down-coded to a lower level of care, no medical documentation submitted for the date of service billed, and insufficient documentation to support code 99214, which is defined in the CPT® manual as follows:

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 detailed history;
• A detailed examination;
• Medical decision making of moderate 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, 25 minutes are spent face-to-face with the patient and/or family.

First Coast Service Options Inc. (First Coast) conducted a widespread post payment probe review for CPT® code 99214 for the top three provider specialties billing this code: 06-Cardiology, 11-Internal Medicine, and 08-Family Practice. The overall widespread probe error rates were 15.79 percent, 19.08 percent, and 24.46 percent, respectively. Services were denied due to the findings below:

• Documentation did not meet the “incident to” criteria as outlined in the Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM), Publication (Pub) 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.2;

• No medical documentation was submitted for the date of service billed; and/or


• Services were recoded based on the medical necessity of the visit and level of E&M components demonstrated in the medical records.

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