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!!!!
1. Detailed History:
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:
- Location
- Quality
- Severity
- Duration
- Timing
- Context
- Modifying Factors
- 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.
- Constitutional (e.g., fever, weight loss)
- Eyes
- Ears, Nose, Mouth, Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
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!
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.
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.
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…….
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.
- 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
- 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
- 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….
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)
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
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.
