Optimize Reimbursement
Via Level 4 and 5 Outpatient Codes
A detailed
review on how to and when to bill a 99214 or a 99215 is explored.
By Douglas
J. Jorgensen, DO, CPC
Knowing
exactly what code to bill is the key to optimum reimbursement.
An example is when should a family physician bill a 99214 or a
99215? This question refers to what is commonly called “Level
4” and “Level 5” established outpatient codes or
99214 and 99215, respectively.
While these codes are close in their numerical order, they are not necessarily
to be coded for the same type of visit, nor are they, or should they be, coded
very regularly. For ease of interpretation, we will assume the 1995 federal
documentation guidelines are in effect (these are the most commonly used and
more lenient in terms of compliance.)
The 99214
The 99214 requires two of the three key components made up of the history,
exam and medical decision-making (MDM). In this case, a detailed history, a
detailed examination, and moderate complexity medical decision-making are requisite.
History
A detailed history mandates an extended history of present illness (at least
four elements describing the chief complaint), and extended review of systems
(a.k.a. ROS and in this case extended means two-nine systems reviewed) and
a pertinent (mention at least one that is germane) PFSH or past family, medical
and/or social history.1
Exam
The detailed exam is five to seven body areas or organ systems and a moderate
complexity MDM could easily be established with prescription drug management
of > two acute medical problems or one or more chronic issues that are worsening
or in an acute exacerbation. Let us look at this practically.
If you had a run-of-the-mill URI or otitis media, most of us would likely charge
a 99213, as that is a middle of the road routine visit. Based on strict interpretations
of the 1995 guidelines you would easily reach this code and possibly a 99214.
However, most providers would agree that a 99214 is too high a visit charge
for such a straightforward encounter.
While undercoding is also unacceptable, routinely charging 99214’s just
because you can makes you a statistical outlier and potentially invites an
audit. Thus, in order to legitimately charge a 99214, one should look for those
cases where your routine workup and treatment has an added twist.
If you had a patient who had systemic rhus dermatitis, an otitis media
and a paronychial infection this too, assuming the documentation warranted
it, could be charged as a 99214. If addressed individually at separate visits,
these would likely be 99212’s or 99213’s due to the low-level of
complexity. However, when multiple acute issues are addressed simultaneously,
you are indeed justified to bill accordingly.2
The 99215
Regarding the 99215, this should be a very uncommonly used code. To begin,
you must have a comprehensive history (extended HPI, complete ROS— >10
ROS—and a complete PFSH), a comprehensive exam, and high complexity MDM.
The ROS
The ROS needs to be areas or organ systems that are germane to the chief complaint(s)
and the exam needs to cover >eight body areas or organ systems or be a “complete
single system exam.” For the “complete single system exam,” it
is advisable to use the 1997 guidelines definition of a complete system since
the feds were kind enough to define it for us.
MDM
High complexity MDM typically poses a threat to the life of the patient or
is a severe exacerbation of chronic issues. If it is severe than it too would
likely pose a threat to life.3 I would recommend caution in billing this code.
These should be your sickest patient visit(s) of the year and it has been my
experience that patients who need this level charge are often hospitalized.
If that is the case than the inpatient initial hospital visit code would supercede
the outpatient code making the point mute. Thus, I rarely if ever use this
code.
Douglas Jorgensen,
DO, CPC is a family physician with Manchester Osteopathic Healthcare
in Manchester, Maine. He is a Certified Professional Coder, and
the founder of Jorgensen Consulting, a national professional
service organization offering educational forums and coding consultation.
He can be contacted via e-mail at ems@ctel.net.
If you have any coding questions that you would like Dr. Jorgensen to answer
in upcoming Osteopathic Family Physician News publications, e-mail them to the ACOFP
Publications Department.
References
Jorgensen,
DJ; History: A Vital Clinical and Coding Element; Osteopathic
Family Physician News; January 2001.
Jorgensen,
DJ; How to Examine the Examination and Decide on Medical Decision-Making;
Osteopathic Family Physician News; February, 2001.
