Say you need a new roof on your house. As any responsible homeowner would do, you would get three or four quotes from contractors, right? You don’t want to go with the most expensive one because who wants to pay too much? Nor do you necessarily want to go with the cheapest guy because sometimes you get what you pay for, and you don’t want your roof falling in. That paves the way for the middleman — he’s the “safe” choice. At least so the logic goes.

But does that same logic apply to coding? Probably not. Particularly when it comes to the granddaddy of E&M codes, the 99213. In the range of existing-patient E&M codes, 99211 to 99215, it falls nicely in the middle and seems like such a safe bet. And it’s popular. According to 2007 CMS data, family practice physicians coded 99213s 21.5 million times in 2007; while internal medicine physicians coded 26.5 million 99213s.

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“This is surprising because with Medicare patients, because of their age and the way the health cycle goes, you might expect increasing complexity. I think this means physicians are coding this incorrectly,” says coding expert Bill Dacey. “The patients I see in the internal medicine waiting rooms aren’t there with tennis elbow. They’re there with diabetes, hypertension, or constant back pain. They have more things going on [that] are better represented by a [99214].”

What’s up?

So why are doctors coding level 3s instead of more level 4s? Part of the problem is not knowing what the difference is (or really caring). Another reason is the tendency to forget what complex medical decision making — the main factor in E&M code selection — feels like. As you gain experience as a physician, what once seemed to be a monumental decision-making process becomes second nature.

Another reason for down coding? Fear. With the threat of a CMS audit looming, coding in the middle doesn’t raise any flags, right? Perhaps, perhaps not. CMS auditors not only look for patterns, but also look at individual records. If auditors choose to view, say, 10 percent of your submitted claims for the year and find any improperly coded visits, they can apply that to an entire year’s reimbursements. While the concern isn’t that they will find a pattern of undercoding and owe you money, if your coding doesn’t reflect what you do, they could potentially find an instance of overcoding and that can lead to fines and even felony charges.

“It’s pretty scary. I know of groups who have been charged upwards of $800,000 in fines from CMS,” says Michael Stearns, MD, who is a certified coder and CEO of e-MDs, an EHR vendor. “What’s funny is they say it’s equally bad and fraudulent to undercode, but no one takes that very seriously. Still, you don’t want to play with CMS.”

What is it?

So before you place yourself on autopilot and check off another 99213, consider what that really means. To properly document for this encounter, you must meet two of these three criteria:

• An expanded problem-focused history.

• An expanded problem-focused exam.

• Low-complexity medical decision making.

Or it can mean 15 minutes spent with the patient if coding is based on time. Of course, you can only code based on time if more than 50 percent of the total visit was spent counseling the patient face to face.

A 99214, on the other hand, requires at least two of these three key components:

• A detailed history.

• A detailed examination.

• Medical decision making of moderate complexity.

The big difference is the level of decision making. Some clues that you are dealing with a visit where you are actually making these moderately complex decisions:

• A new complaint that could become serious if left untreated.

• Three or more old problems.

• A new problem that requires a prescription.

• Three stable problems that require medication refills.

• One stable problem and one inadequately controlled problem that require medication refills or adjustments.

Take note

But it’s all in the documentation and note-taking. How many possible diagnoses did you consider? Why did you narrow it down to one? What was your follow-up? Again, it’s all about the notes, but many physicians fly through these decisions and recommendations so quickly after years of practice they scarcely notice they’ve done the work, let alone document it.

“When I go into practices very often I see documentation that supports a four, but they [undercoded the claims] because they didn’t realize was what was needed” for the higher code, says Stearns.

Also, while playing it safe by staying in the middle seems like the easy road, consider this: You are very likely leaving income — your income — on the table and auditors can still come in and look for errors on individual claims. The best bet is to do it right and back it up with proper documentation. Otherwise you might end up paying a high price for inadequate payment and your roof could seriously fall in.

Kellie Rowden-Racette is a former associate editor with Physicians Practice. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the July/August 2009 issue of Physicians Practice.