Level 5, Part II

June 15, 2011

Level 5 codes based on "breadth of management" need to clearly explain "why" the reported illnesses pose significant risk to patients. Should the physician add a statement to to her assessment that explains why the combination of multiple chronic illnesses pose a risk to the patient's morbidity/mortality?

Question: In your previous answer to my questions about carrier review of high level codes you said to make a statement regarding, "Several chronic problems which are either worsening or stable but when taken together have the effect of creating a high risk situation." You stated that levels 5 codes based on "breadth of management" needed to "feel" like a level 5 and clearly explain "why" these illnesses combined posed such a risk to patients. Is your recommendation that I actually add a statement to my assessment and/or plan area that explains why the combination of these multiple chronic illnesses poses a risk to the patient's morbidity/mortality? (From the March 2011 journal.)

Answer: Yes - that's it exactly. The discussion of level 5 codes leads to discussion of the "gray area" of the Medicare guidelines that do not specifically mention any number of chronic illnesses that are required to make up a level 5 visit. Remember, the first medical decision making (MDM) table counts four stable problems as "high" level MDM, but the table of risk simply talks about high risk examples at level 5 and doesn't give you a number.

We are all up against an unknown, or un-quantifiable, element in the Medicare documentation guidelines - namely that third part of the decision-making tables and the challenge of either quantifying or evoking the "sense" of high risk.

There were sample statements at the end of your e-mail:

Examples of various statements at end of Level 5 visits documenting "multiple, chronic stable illnesses":

1) As evaluated and managed above, patient has multiple significant cardiovascular risk factors that place patient at high risk for serious complications such as ischemic heart disease, heart attack, stroke, etc.

2) Due to coronary artery disease and other multiple comorbidities, patient is at higher risk for myocardial infarction (MI) and other serious cardiovascular complications.

3) Patient's diabetes mellitus and comorbid conditions place patient at high risk for serious multisystem, microvascular, and macrovascular complications such as retinopathy, nephropathy, neuropathy, coronary artery disease, etc.

4) Patient's uncontrolled HTN places patient at high risk for heart attack, stroke, or other serious complications.

These are certainly a step in the right direction. If nothing else they say "high-risk," they mention one of the more recognizable examples mentioned in the table, i.e. MI, and do convey a sense of risk.

On the last one, remember that "uncontrolled" could be further modified by "moderately" or "severely" - that there are degrees of non-control. The word severe appears in the list of examples too on the first bullet in that table of risk. Go that way if it is more of an M/M problem with one thing rather than the breadth of management and collective risk issue.

Although these examples move you in the direction of what we are looking for, and in any given chart may well do what we need them to do, I still want to caution you to amend them as needed to reflect the specific issues and gravity pertinent to that patient that day. Don't say "the patient's uncontrolled HTN ..." or "the patient's diabetes…" - say "Mr. Smith's uncontrolled HTN..." and "Mrs. Smith's diabetes..." Remember that the OIG is concerned about cloning - don't overwork these statements.

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. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the April 2011 issue of Physicians Practice.