When to bill CPT code 99214

According to EM university, in 2003 this code was used 56.7 percent of the time for internal medicine coding. It is no surprise that we like this "middle of the road" code. The problem is, just because we think it is middle of the road, doesn't make it so. In fact, I would say that the 99213 is so remarkably similar to the 99214 that you may be surprised how very many 99214s you are missing by picking the road most traveled.

Let's take a look at the anatomy of the 99213..

The 99213 is a visit with an established patient that you have seen in the LAST 3 YEARS......which requires a certain level of work and documentation. These requirements are:

1. An "Expanded" Problem focused History
2. An "Expanded" Problem Focused Examination
3. Medial Decision Making of Low Complexity

As you can see, this is made to look like the 99212 except "Expanded" which is why people think it is, to quote Goldilocks......"Just Right"

I beg to differ. In fact I think once you have the needed elements for a 99213 you may be surprisingly close to a 99214.

It all comes down to the documentation.

Lets look at each Element

  • The "Expanded" Problem Focused History
What the hell does that mean????
This history requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.

Are you telling me that you don't do a review of Past Family, Medical or Social History with each patient? Isn't that what they want us to do with medicine reconciliation??

So likely you will exceed this requirement. An ROS of ONE system? Why do just one? I can think of a million reasons why even simple complaints need more than this.
  • An "Expanded" Problem Focused Examination
Do you remember bullets? Not dodging them.....hitting them. In the 1997 physical exam rules a bullet system divided organ systems up into the sub exams...i.e. Conjunctivae, Sclera, Fundus for the eye.....

In the "Expanded" Problem Focused Examination you need, 6 bullets from ONE or more organ system......
Vitals signs? 1 Bullet
General Appearance? 1 Bullet

So all you need to do after this is examine 4 other "things" in the same or other organ systems.
Don't remember bullets?

The problem is that to reach the next level, you need a much more comprehensive exam. But, the big kicker is that with established patients 99212, 99213, 99214, 99215 you only need 2 out of 3 categories to bill at the highest level. So you may qualify for a 99214 without doing that thorough an examination......Don't let your "Gut" tell you what to code.

The third category as always is the Medical Decision Making........otherwise known as the MDM

In this case, for the 99213 you need low complexity medical decision making......this is what bugs me.........just because your patient is "middle of the road" doesn't mean his MDM is.....

Which is the point that is being made here by the AMA. Is "Low Complexity Medical Decision Making" middle of the road for what you do? Probably not. Diabetes? Not really low complexity. Hypertension, a lot of the time this is not low level either. I view low level like the AMA views low level...In essence, the patient could come in with just ONE chronic problem, Which is STABLE and you make the MDM case. We start with the Points........Yes, MDM is divided up in 3 parts

1. Problem Points-In this case, you need 2 problem points? Do you remember the points per problem?

2. Data Points-These points are for data you review or order. In the 99213 you need 2 of them as well.

3. Risk-I really love this one. Low risk is "Only Marginally Higher than Marginal Risk" WTF? Ok, so just about everything outside of bug bite qualifies as at LEAST Low Risk. Which means, you probably are undercoding if you select 99213....

You should always ask yourself as you put 99213 down on the superbill........Is it really JUST a 99213? Chances are, you would be incorrect and it is in fact a 99214. Remember, just hitting MDM and History gets you a 99214 instead of all 3 being required in the New Patient 99204.

Want to see a 99213?

Here we go,

A 56 year old man present for follow up of well controlled hypertension wishing to change medications. He has absolutely no other complaints......

Anything above and beyond and you should start thinking about a 99214

1 comment:

Unknown said...

I think there is an error in your advice. for MDM, just because the "RisK" is low, doesnt mean your MDM is "Low Complex".
It depends on the Dx and Data as well. If your Data is only 1 point, (i.e. order one lab), and your Dx is 1 point (i.e. 1 chronic stable illness) your MDM only counts toward "Straight Forward"

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