I received the following question recently. I'd like to discuss it today because this is one of the seven essential items to protecting your charts from audits that we will discuss this year. This item is very simple: Do a detailed history on level 4 patients.
Question: A patient has uncontrolled mild intermittent asthma. I understand that risk would be moderate. However, the point system from medical complexity gives you only 2 points for "established worsening problem." Due to the measly 2 points from the point system, wouldn't this end up being a low complexity medical decision making and thus only qualify for a level 3 visit (mod risk, 2 points for "Number of Diagnosis and Management Options, and 0 for data review)?
Answer: This question demonstrates two points for us. The first point is not all states and insurance carriers use the same coding guidelines. When we discuss 'diagnosis and management options' we usually count each diagnosis as one point and each management option as one point. This doctor uses a system that only counts the number and types of diagnoses with no regard to management options. So using their system, their level of medical decision making would not exceed the Low Risk category.
My first advice is that if you have a patient with moderate risk and a note that supports a 99214, then you should bill a 99214. Here is what I would suggest: Do a detailed physical exam (an extended exam of the respiratory system plus other related or symptomatic organ systems). This would be standard of care for this patient's office visit. Look at this HPI:
Patient is here for follow-up of mild intermittent asthma. Over the past 3 weeks has had increased albuterol usage which does improve his peak flows back above the 80% range. Lots of coughing. Currently he is taking Flovent 110mcg 2 puffs bid, Singulair 10mg q HS, and Albuterol MDI 2 puffs prn. No side effects reported. No other respiratory or ENT symptoms.
This simple but appropriate history is a detailed history. We have 4 elements of HPI (location, duration, modifying factors, associated signs/symptoms), 1 element of PFSH (medication list), and 2 elements of Review of Systems.
If you document a detailed exam with this history, then you have a perfectly good 99214 note. Your level of risk is appropriate for a 99214. Even though your level of Decision Making is not Moderate, it doesn't matter since you've met the requirements of 2 out of 3 for history, exam, and decision making.