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How To Use The ICD & CPT Codes To Avoid Prosecution And Possibly Prison
CPT: Medical Coding Roundtable: Why 99214 Is Your New BFF
Code 99214 ranks as the second highest level of care for established patients, yet stands as one of the most underutilized codes out of the CPT book.
It is commonly thought that physicians may down-code to a 99213, if the physician is not sure their documentation supports a level 4 established patient visit. They leave a lot of money on the table that they are legitimately entitled to, if they just understood some simple basics that support a 99214.
There are several possibilities that could lead a provider to under-code a 99214. They are as follows:
Dollars and Sense (99214’s BFF Qualifications)
Some studies have indicated that aggregately, 37.3% of internists use 99214 for established patients. That is not a high number of providers utilizing this code, especially when the 2012 national Medicare (CMS) reimbursement for this visit is approximately $104. In other words, that’s a lot of money being left on the table due to fear or misunderstanding of how to properly code 99214.
Mind Your Minutes
Providers must remember that time is also a factor when it comes to coding to a higher level. Once the decision has been made to code a 99214, be mindful of the time spent with the patient. If the provider spends at least 25 minutes with the patient with more than half the time involved with counseling or coordination of care, 99214 is appropriate to code.
NOPP – Nature of the Presenting Problem
As with all high level codes, the provider must bear in mind that the presenting problem must be of moderate to high severity for a 99214. As long as the documentation of the presenting problem is consistent with medical necessity (which is the overarching criteria for code selection), the next step is ensure that the documentation is bulletproof, in the event of an audit. It is essential that the provider thoroughly and accurately documents each step of the visit to support the code being billed.
Documenting all diagnosis codes/problems discussed during the visit is a good way to ensure and support medical necessity for coding a 99214 (or any high level code).
Making 99214 Your BFF
CPT 4 defines 99214 as an “office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components”:
With that being said, documenting a 99214 is relatively simple. Since CPT 4 says that only two out of three key components must satisfy the documentation requirements for any particular level of care. It is up to the provider decide which elements to document, as the amount of required documentation is quite simplistic.
Step right up and get TWO of THREE (History, PE, MDM) to code for 99214. Some providers may find it easier to get to a 99214 by working in reverse through the elements to establish moderate MDM by documenting a combination of the following:
o OR 2 or more STABLE chronic illnesses. Yes, STABLE
o OR 1 chronic illness with progression or side effect of treatment
Key Points to Remember for 99214
Apply 99214 for any of the following:
The take-away from this lesson is that 99214 can be every provider’s BFF by keeping the following in mind: remember to take the time to quantify the MDM in the required documentation so that your record is bulletproof and supports your 99214.
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