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Your Top Coding Concerns Solved: Leveling With Your Payers


Level with your payers; how to code for “easy” and “hard” cases.

When trying to determine what makes physicians select a given E&M code level, one often finds that the answer depends largely on whether they consider the encounter to be “easy” or “hard.”

While that may make sense in a particular provider’s subjective opinion, it’s no way to code. You won’t find the distinction between “easy” and “hard” defined in the CPT manual or in federal documentation guidelines.

For more objective guidance, look up the definitions of medical decision making based on federal guidelines in the CPT manual’s “Table of Risk” under the “Presenting Problems” column. Later versions label this column “Number of Diagnoses and/or Risk of Complications.”

Here, straightforward medical decision-making is described as “one self-limited or minor problem,” meaning that a single problem brought to your attention will most likely resolve on its own. These problems include bumps, bruises, and the symptoms presented during “worried-well” visits. How about a follow-up-otitis visit for a child who at a glance appears quite healthy? This may well be a level 2 - or 99212 visit - if only a cursory exam is required.

But physicians tend to group other seemingly “easy” visits into the 99212 category as well. For example, consider URI- or UTI-type symptoms presented by an otherwise healthy adult, no differential to note, who requires a few simple questions, an examination of two to four organ systems, and either symptomatic treatment or a single prescription. This is not a condition that will resolve on its own. It’s a level 3 - or 99213 - visit.

Similarly, level 4 visits are too often downgraded to level 3. The CPT manual defines a level 4 visit as one in which the patient presents “one or more chronic illnesses with mild exacerbation, progression, or side effects of treatment; or two or more stable chronic illnesses; or undiagnosed new problem with uncertain prognosis or acute illness with systemic symptoms; e.g., pyelonephritis, pneumonitis, colitis.” Get the idea?

Pay special attention when coding for visits in which a patient presents “two or more stable chronic illnesses.” That could describe every Medicare patient you ever saw, so stick with three or more stable chronic conditions when coding a visit as a level 4 to give yourself safe harbor.

Evaluating three stable chronic problems calls for a level 4 - or 99214 - each time if you properly document that patient’s relevant history, exam, and management.

Documenting your decision-making

We’ve discussed how to select a code, but what paper trail must you leave behind to document your work?

Physicians often miss some fundamental elements of documentation, as the one-size-fits-all guidelines they consult cannot neatly describe all encounters within each of a wide variety of specialties. This is especially true when it comes to documenting medical decision making. What are payers looking for?

If you examine any of the tools commonly used to determine medical decision making levels, a consistent theme emerges. To determine the level of work a physician performs and the subsequent documentation required to justify that work, a provider must make clear how many problems are being evaluated or managed, the status of those problems, and how they are being managed. That sounds easy enough, but physicians muddle their documentation on a regular basis.

When documenting a patient’s different presenting problems, lay out each one this way: diagnosis, status, and treatment or prescription. Don’t record the problems presented and then list medication changes that aren’t necessarily linked to the management of those problems. Instead, for each problem, clearly link your diagnosis, status, and treatment; this illustrates the disease management payers look for.

For your 99212s, you don’t need much documentation. Simply state the problem and its treatment or lack thereof. For 99213s, describe the patient’s single acute problem or two stable chronic conditions, and then describe your treatment. Don’t simply note, “Continue same,” “Refill all,” or “Follow up three months.”

For the 99214s - which are very important because they no doubt cover many of your Medicare patients - make sure you know how to document a chronic disease follow-up visit. Lay out the patient’s three stable chronic problems, the status of each, and their management. Set up the A/P area of your documentation to mirror the patient’s history and physical. For example, the documentation of a 99214 visit may look like this:


  • HTN, pressures running in the 130s, no dizziness, salt intake down.

  • Dyslipidemia, exercises daily, still taking red rice yeast extract, no muscle aches.

  • COPD, using inhalers PRN, wheeze reduced w/recent jogging.

Match this up with your notes in the A/P area:

  • HTN, stable, continue (medication name).

  • Dyslipidemia, continue exercise and supplements, labs today.

  • COPD, continue inhalers as needed and (medication name).

In these cases, the level and the nature of the visit are obvious at a glance. We’ll stay away from the 99215s for now. Master the 99214s first - and get paid more for the work you’re already doing.

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 over 18 years. He can be reached at billdacey@msn.com or via info@physicianspractice.com.

This article originally appeared in the September 2007 issue of Physicians Practice.

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