Level 4 Documentation; RN Reimbursement

April 1, 2015
Bill Dacey

Answers from our coding expert on questions regarding Level 4 documentation and RN reimbursement.


Q: I'm a podiatrist and my office manager tells me that some of my Level 4 (99214) notes are not sufficient. Can you tell me if this note supports that level and the procedures documented?

The Note:


1 - The patient is seen in the office with chief complaint of intense pain on top of the nail X 10.

2 - The patient has hyperkeratotic lesion submet 3 R. Patient has HD on 3 R.

3 - The patient is seen in the office with chief complaint of intense pain on hallux B/L.


1 - The patient described the pain as a throbbing pain especially wearing shoe gear or when attempting activities for the past few weeks, but pain is better when not wearing shoes and off weight bearing.

2 - The patient described the pain as a throbbing pain especially wearing shoe gear or when attempting activities for the past few weeks, but pain is better when not wearing shoes and off weight bearing.

3 - The patient described the pain as a throbbing pain especially wearing shoe gear or when attempting activities for the past few weeks, but pain is better when not wearing any shoes.ROSCardiovascular - Denies any cold feet.

Constitutionally - Denies any fatigue.

Neurologically - Denies any numbness.





Physical Exam

Derm - Skin color is Normal bilateral. Skin texture is Normal bilateral. Skin temperature is Normal bilateral. Hair growth is Normal bilateral. Plantar scaling/exfoliation is Present bilateral.

Vascular - Dorsalis pedis pulse, right foot is Normal. Dorsalis pedis pulse, left foot is Normal. Posterior tibial pulse, right foot is Normal. Posterior tibial pulse, left foot is Normal. Digital capillary return is Normal bilateral. Varicosities are Present bilateral. Lymphedema is Present bilateral.

Constitutional - Well developed and well nourished.

Psychological - Alert and oriented X 3 and in no acute distress.

Muscle power - Normal.

1 - Nails appear dystrophic and discolored + subungual debris + tenderness upon ambulation + digital hair + shiny skin. There is inflammation of the skin along the edge of the nail. Nail appearance as a whole is brittle.

2 - HD secondary to hammer toe.

IPK submet secondary.

Atrophy of the plantar fat pad.

Ability to palpate prominent metatarsal heads.

Dorsal contracted toes at the MPJ.

Moderate to severe pain on the plantar aspect of the FF when the patient ambulates.

3 - Stage one ingrown: erythematic, slight edema and pain when pressure applied to the nail fold.


1 - Foot pain (729.5)

Onychomycosis of the toenails (110.1)

2 - Hammer toe (735.4)

Metatarsalgia (726.70)

Callus (700)

3 - Ingrown nail (703.0)


1 - After verbal consent was obtained from the patient, with the risks, benefits, and alternatives explained, debridement of nail X 10 was done. PTR: 3 MONTHS. Continue current meds.

2 - After verbal consent was obtained from the patient, using ethylchloride the lesion is enucleated with a blade through the stratum corneum on submet.

3 - After verbal consent was obtained from the patient, with the risks, benefits, and alternatives explained, used ethylchloride spray and then did a partial nail avulsion done on B/L hallux. Made sure no residual nail plate remained under the nail fold. Applied SSD cream and Betadine. Bandage to remain intact for 24-48 hours.

A: Your note technically meets the requirements for a 99214 and a nail debridement, either a lesion excision or debridement for the "HD," and either a partial nail avulsion or wedge excision of ingrown nail.

On the latter two, the exact method or language is important to distinguish between service codes. I suggest you use a more formal procedure note in each of these cases.

That said, even though the 99214 is technically supported, there may be some blowback from payers on a note like this, as the "management" portion of each of these problems is a separately billable procedure.

My suspicion is that most payers are not going to want to pay on all four codes.

This is part due to what you did in the CC and HPI portions of the note. In the CC, although you spelled out three problems, you used a kind of "cut and paste" appearing language with the repeated "patient is seen in the office with chief complaint of ..."

Although the subject changes, the visual impact is one of cloning. It is pretty clearly "smart text" or stock phrases lined up on top of one another. The CC should probably read, "Patient is seen in the office with chief complaints of nail pain, hallux pain, and a submet lesion." That is the "concise" statement payers are looking for.

You really don't want to do what you did in the HPI - use three identical statements, as this says the opposite of what you want to convey with your codes. Your modifier -25 on the 99214 says that these procedures are separate and distinct, this HPI lumps them all together and provides none of what payers are looking for in terms of duration, severity, modifying factors, quality, etc. We really only have location.

So some of the information you have listed in the CC section should go in the HPI, making each problem distinct and detailed. You must avoid the cut and paste approach and type this information in. I realize that you are looking for efficiency here, but if you think you did Level 4 E&M work and three procedures - and you want to get paid for it all - then the documentation is going to take a little work as well.

A cut and pasted, patchwork-looking note isn't going to impress anyone, least of all a payer.

The ROS is fine. The exam is pretty good, but would be better if the foot exam section had a label like the systems above (I am getting picky here). Just call it feet, or put it under Derm. I'd also say a bit more about MSK.

The plan section would be better with formal procedure notes. It wouldn't hurt to add a sentence, particular to the patient - not a cloned statement - that speaks to the moderate risk of complications and risk to the extremity with the multiple problems, if in fact that is true. It would help support moderate decision making.

Although the problem count is correct for a 99214, your note looks too much like a collection of "smart text." It would definitely hit an auditor's cloning nerve, and would also likely strike an auditor as somewhat short on the "separate and significant" aspect of the E&M in relation to the procedures. The fact is that if the treatment of the problems is the procedure, and there is any sense that the patient is presenting for the purpose of the procedure (like the nail debridement in this case), then that "problem" may not be counted in the decision making.

I'm not trying to be unduly critical, and I'm not trying to give a vague answer, but with this collection of problems it is difficult to determine exactly how a given payer would respond.

If you take all the suggestions I gave above, you will be much closer to a supported 99214. If you don't, a 99214 would probably be down-coded to a 99213.


Q: I work for a public health agency where our RNs provide a great deal of face-to-face services to patients. For example, they may spend one hour with a pregnant patient doing all of the preliminary assessment and evaluation, lab work, etc., in preparation for a visit with the physician or NP at a later date. Can you offer any advice on how we might be able to bill third-party payers for this particular type of visit? We also have a similar situation with patients who have tuberculosis or other communicable diseases. In these visits, the RN does all of the assessment and discusses medications and sometimes administers them. The RN may even go over lab results at subsequent visits, and so on. The patient may never have a face-to-face with the physician. These tasks are all within the public health RN's scope of practice, but there doesn't seem to be an easy way to bill for reimbursement.

A: What you describe is not unusual in either a public or private practice. I have some answers specific to your circumstances though, and some general guidance as well.

I think most people's impression of a public health agency would be that it is free, so your question surprises me a bit. If it is not free, then my first question becomes whether or not the agency bills some type of facility charge or visit charge. If so, then the services of the RNs would be included in that facility charge and not represented on the professional billing side of reimbursement.

You indicated that the patient may see a physician or NP at a "later date" and the suggestion is that those visits are billed. Those visits can be billed if their professional licensure allows them to obtain NPI numbers and become credentialed with Medicare and commercial payers. Some advanced practice nurses can do this, but the majority of RNs cannot.

If your RNs are employed by the physician/NP professional entity, not the "agency," then there are circumstances where they could bill a 99211 for some of the services you describe above. But first you need to determine what type of entity you are, and whether the RNs are employees of a facility or of a professional medical group.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years.

This article originally appeared in the April 2015 issue of Physicians Practice.