Coding the right level

According to published statistics and my experience auditing medical records, physicians mainly use code 99213 for established office visits and rarely, if not at all, use code 99214. I have seen many cases where the medical record warrants the higher level, however physicians automatically or routinely select the lower level code without any consideration for the higher one. This practice of under coding possess a potential loss of revenue and physicians may be shortchanging themselves.

The impact on revenue can be substantial. Suppose, for example, if a physician sees 25 patients per day and under codes 25% of all the visits.

Based on Medicare rates, the difference in reimbursement between a 99213 and a 99214 is over $30 per visit. Therefore, this physician would lose over $187 daily or more than $45,000 annually. This is a considerable amount of money. So what is required to bill a 99214? Code selection for an established office visit is based on any two of the following three components: history, exam and medical decision making. The medical decision making component may be used as prime to establish the 99214 visit as one would not perform a detailed history and exam if the presenting problems did not necessitate it. Assuming that, medical decision making of moderate complexity must be justified; the following lists circumstances that would apply.

  • The patient has a new problem that requires a prescription.
  • The patient has 3 or more old problems.
  • The patient has 3 stable problems that require medication.
  • The patient has one stable problem with one inadequately controlled problem that requires refills or adjustment of medication.
  • The patient has a new complaint with a potential for significant morbidity if untreated or misdiagnosed.

Additionally, if medical decision-making is of moderate complexity, either a detailed history or a detailed exam must be performed to meet the requirements for a 99214. Also, if the physician spends at least 25 minutes face-to-face patient time and more than 50% if the time is spent counseling and coordinating care, then time drives the level and the above components are not considered. If this is the case, the time must be documented in the medical note. If you suspect you may be under coding, Medorizon can service you by providing chart audits or educational seminars.