Hey everyone! We will continue with the Q&A theme for this week's newsletter.
Question:
Since taking your course, my coding level has improved and increased which has triggered an audit by my employer. The auditor tells me that the level of coding is a "gut feel by the physician", and how long the encounter with the patient lasts. For example, 3 stable chronic problems for which the patient is following up, is not a level 4, but at best a level 3, because they are stable, and you are not changing any thing; they are continuing on their meds etc. Also, a new problem such as bronchitis etc, being treated with antibiotics is not a level 4, even though you document a detailed H&P, with the pertinent ROS, because prescribing a prescription medication is not the same as prescription drug manangement as stated on the 1997 risk table. Finally, she states that your codes should fall in a bell shape curve, with the middle being the most codes at level 3.
Answer:
As far as I can tell, anytime you are audited by Medicare, Medicaid, or other payers, they are not allowed to audit you based on a 'gut feeling by the physician'. Granted, the length of the visit can lead to a certain level of service if you spend most of your time in counselling or coordination of care. But, that is documented in the E&M guidelines; it is not a gut feeling.
The Medicare guidelines are very clear: follow-up of 2 stable chronic problems (or more) or prescription drug management are both moderate risk activities. Now, whether you meet the criteria for a 99214 is based on history, physical exam, and decision-making (of which risk is a part). But if you fulfilled all the requirements, then that is how you determine your level of service. Of course, you never 'buff up' your history and physical just to get a higher level, but if you did the necessary work and documented it, then you get credit for it.
Codes should fall in a bell-shaped curve only if your patients are in a bell-shaped curve. Some days I see lots of follow-ups for problems that have resolved (99212). Some days I see lots of multiple chronic problem patients (99214s). I have friends that do geriatrics that spend 45 minutes in counselling with every patient (99215s). No where in the coding guidelines does it say you should have a bell-shaped curve. No where in the coding guidelines does it say to go with your 'gut feeling.' And if you get audited and go to a hearing or trial, the only defense you will have is the coding guidelines.
Don't know if this helps. But if I pay money to any 'expert' and they tell me to code in a way that is different than the Medicare guidelines, I would make sure they show me documentation from the government that supports their claims. What if they told you to trust your gut and code everything higher? Don't trust your gut. And don't trust what people tell you (including me). You must go by the published guidelines.
Question:
Some insurances pay only if there is a new diagnosis at the time of physical or adjustment of medicines. They do not pay for monitoring chronic health conditions such as hypertension with preventive physical. How I can be paid for monitoring chronic conditions with a preventive physical?
Answer:
If you have an insurance company whose policy is to only pay for health maintenance and problem-oriented visits if the sick visit is a new diagnosis, then there is nothing you can do to fight it. Many payers have a policy of never paying for health maintenance and problem-oriented visits on on the same date of service.
What I do is tell my patients that their insurance will not let me do a Healthy Checkup and a follow-up for the chronic problems on the same date (if they refuse to pay, that is in essence what they are saying to you). Then have them come in another day for the other visit. Which is very inconvenient for the patient, but you may have to do it. Many physicians just do the work anyways and don't get paid for both. Not a good solution but very typical.
One main thing to remember: if you bill a health maintenance and problem-oriented visit for the same date of service using a -25 modifier, you must be sure that the 'sick visit' does not constitute an 'insignificant or trivial amount of work' compared to the work you did for the well visit.
Question:
I recently did a comprehensive consultation on a diabetic who also had
multiple other chronic problems. He had comprehensive history and physical. My
auditor told me it was only a level 4 visit. I believe the Medical Decision
Making would be considered High Complexity. The number of diagnoses or
management options is extensive. Currently there are around 40 different
medications used to treat diabetes itself. This gentleman has a serious diabetic
related complication, systemic atherosclerosis, which historically will kill
~80% of the diabetic patients Endocrinologists treat. Other treatment
considerations bear on this condition. His lipids and blood pressure need to be
controlled. Medications/interactions for these associated conditions are also
extensive. The Risk of Complications and/or morbidity or mortality is
significant in diabetic patients as noted above. About 80% of diabetics
historically will die of atherosclerosis, which is directly related to the
diabetes. These patients account for a huge proportion of heathcare costs
because of these complications. I know of few other chronic diseases which have
as poor a prognosis as poorly treated diabetes. Control of the diabetes is a key
factor in reducing the risk of these complications.
Answer:
I may have to disagree with you on this one. To get credit for a level 5
consultation, you must have all 3: comprehensive history, comprehensive exam,
and high level of decision-making. You do have history and exam.
Decision-making must have 2 of the following:
High risk is not determined by anything other than the table provided in the Medicare E&M guidelines. For chronic problems (diabetes), that means they must have either severe exacerbation, severe side effects, or severe disease progression (none of which are documented in your note). That is the only way risk is defined for chronic problems.