A Quick-Reference Carte du jour for Identifying Level-4 Visits

The author'due south tool will help you proceed in heed what qualifies a visit for a 99214 or a 99204.

Fam Pract Manag. 1999 Jul-Aug;half dozen(vii):32-34.

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Article Sections

  • Introduction
  • 99214 in a nutshell
  • Documentation aid
  • Level-4 visits with new patients
  • The mantra: Document everything

Coding and documentation of evaluation and management (E/M) services: This has to be the topic that physicians detest to read nigh most. Equally nosotros all know, the "guidelines" for coding and documentation are really a morass of rules that seem to encourage downcoding by making the rules vague and the penalties harsh. The "new framework" for the documentation guidelines, expected to be released subsequently this year, may make the rules more plain — or information technology may not. Thus far, at to the lowest degree, revision has non made the arrangement whatsoever easier to use.

As if you need disarming on this point, here'due south an example of the guidelines' user-unfriendliness. My group recently underwent an audit. 4 professional coders each spent twoscore hours reviewing a total of 100 dictations. That's 1 hour, 36 minutes for each dictation. If it takes a professional person coder — with manuals in hand, specific training and years of experience — more than an hour and a half to review a single note, consider the challenge we face in documenting our services and coding accurately in the few minutes nosotros have betwixt patients.

I think it's fair to say that most of us code by a mixture of rote memorization and gut instinct. We develop a coding gestalt (endeavour explaining that to an auditor). But in doing so, most of usa tend to play information technology prophylactic and undervalue the work we do. Equally I teach coding to residents and attending physicians, the instance of this I run into most frequently is coding 99213 for a visit that claim a 99214.

For me, information technology'southward piece of cake to identify a level-3 visit, and I think most doctors have a sense of what one feels like. I go through cycles, after I've boned up on what's needed for a 99214, when I'm ameliorate able to recognize i when I meet information technology, and my level-4 visits increment. But after a few months I forget a few nuances, and I start shying away from the level-4 codes in order to avert fraudulent billing. What helps me is something that in whatsoever other environment I'd call a "crook sheet" — a reference card to help me remember what qualifies a visit for a level-4 code.

KEY POINTS:

  • A few simple rules of pollex can help you remember when a code of 99214 might exist indicated.

  • The author uses his reference bill of fare as a reminder of what must be documented to support a level-4 code.

  • The card also details the differences in documentation requirements for level-4 visits with new and established patients.

99214 in a nutshell

  • Abstract
  • 99214 in a nutshell
  • Documentation assist
  • Level-4 visits with new patients
  • The mantra: Document everything

According to CPT, 99214 is indicated for an "function or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity." [For more than detailed guidance on when to cull this code, see "99214 Made Easier," Apr 1997, page 51.]

Do you lot find it difficult to recall what that means every bit you meet patient after patient, day after solar day? For me, it helps to eddy down the common indications for 99214 to a few simple rules. (Run across "Rules of Thumb for 99214.")

Rules of thumb for 99214

Think 99214 in any of the post-obit situations:

  • If the patient has a new complaint with a potential for pregnant morbidity if untreated or misdiagnosed,

  • If the patient has three or more than old problems,

  • If the patient has a new problem that requires a prescription,

  • If the patient has three stable problems that crave medication refills, or ane stable problem and i inadequately controlled trouble that requires medication refills or adjustments.

Documentation help

  • Abstract
  • 99214 in a nutshell
  • Documentation help
  • Level-4 visits with new patients
  • The mantra: Document everything

To make our apply of level-iv codes more than consistent and to reduce the corporeality of time we spend on coding, I've developed a tool for myself, my partners and our residents — the " Level 4 Reference Carte." On the front, the card lists the major criteria that your documentation must meet to authorize a visit as a 99214 (any two of the following: a detailed history, a detailed exam and conclusion making of moderate complexity), and it summarizes the elements that must be documented to meet each criterion. It likewise includes a box list how the requirements for a level-iv visit with an established patient (99214) differ from those for a level-4 visit with a new patient (99204). On the back, the menu lists the systems and body areas that may be included in the general multisystem exam, complete with all those bullets to count. Keep in mind, of course, that the reference carte applies to the 1997 version of the documentation guidelines only. [FPM plans to publish an updated version of the reference card in one case the revised guidelines are finalized.]

Y'all can use the reference card in at least two ways: First, with the menu tacked to the wall where you dictate, you can follow forth equally you tape your notation, making certain that your dictation includes all the details that indicated your selection of the level-4 code. In add-on, you lot tin use the reference carte as a guide when you perform internal audits of other doctors' charts.

Internal coding and documentation audits may strike you the way that visits to the dentist strike the general public, but don't underestimate their value. Every medico in our 22-person grouping reviews five dictations per calendar month, and each is a better coder for it. In our practice, the standard is that the physicians should be the coding experts. Nothing teaches me more than about coding than reviewing the dictations of my partners to run into whether their codes are on target and their documentation is complete.

Information technology's too of import to do a little quality comeback with your own coding. One trick we've learned is to add the CPT codes to the lesser of all our dictations, in improver to marking them on the superbills. That way, when we get our dictations back, we tin perform our own mini-audits to ensure that our documentation supports our coding. If we find that we've undercoded, we generally write off the loss. If we find that we've coded also high, we may submit a corrected claim (and our procedure is to hold all our level-4 and -5 Medicare charges until the dictation has been reviewed). But the real value of this practice is that it makes all of us improve coders.

Level-4 visits with new patients

  • Abstract
  • 99214 in a nutshell
  • Documentation help
  • Level-4 visits with new patients
  • The mantra: Document everything

As I review my colleagues' charts and my own, I find that we also normally downcode our moderately complex new-patient visits. The rationale goes something similar this: "The visit would be a 99214 if this were an established patient, but I can't recollect the cut offs for a 99204. And so I'll circular down to a 99203 and keep from attracting some auditor's attention."

A 99214 requires a detailed history and physical exam, and a 99204 requires a comprehensive history and physical examination. As far every bit the documentation is concerned, those differences are manifested in four ways (you'll besides discover these listed on the " Level 4 Reference Carte du jour"):

  • For a 99204, all 3 major criteria (history, physical exam and medical decision making) must exist met. A 99214 requires only 2 of the three major criteria.

  • For a 99204, the review of systems must include at least 10 systems or body areas. A 99214 requires a review of but two.

  • For a 99204, the by, family and social history must embrace all three areas. A 99214 requires just one surface area.

  • For a 99204, the physical exam must cover at least xviii bullets from at least nine systems or body areas. A 99214 requires at least 12 bullets from at least two systems or torso areas.

When nosotros don't go on the rules in heed, we may not include data in the progress annotation that we've obtained during the visit — information that we felt was necessary considering of the patient's condition. Either nosotros simply neglect to mention these details, or nosotros summarize them past dictating things like "Complains of cold symptoms." We enquire the patient what he or she ways by "cold symptoms," but nosotros don't tape the specifics.

If we did include the details, we'd realize that many of these are level-4 visits. For example, a new patient, a 60-year-erstwhile homo, complains of having had a fever, a productive cough, slight dyspnea on exertion, nasal discharge and malaise for the past three days (five elements of the HPI). He denies chills, rash, allergies, dysuria, hemoptysis, sore throat, headaches, breast pain, myalgia, nausea, vomiting and diarrhea (x systems of the ROS). He has a history of exercise-induced asthma and says that his mother and sister have severe asthma; he smokes a half pack of cigarettes per twenty-four hour period; and he works every bit a carpet layer (iii elements of the PFSH).

Dictating about five actress lines of history has put you on track for a 99204. Investing the extra 30 seconds in dictation time and fifty cents in transcription costs tin earn you the actress $thirty y'all deserve.

The mantra: Document everything

  • Abstract
  • 99214 in a nutshell
  • Documentation help
  • Level-iv visits with new patients
  • The mantra: Document everything

The idea, of course, is not to add irrelevant information to your note in order to increase your reimbursement. The thought is to tape everything that you exercise or talk about that is relevant and to bill the code that the documentation supports.

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Dr. Giovino is director of the Mercy Health Arrangement Family Do Residency Plan in Janesville, Wis.

The author thanks Anita Chan for her aid in developing this commodity.

Copyright © 1999 by the American University of Family Physicians.
This content is owned by the AAFP. A person viewing information technology online may make ane printout of the material and may use that printout simply for his or her personal, non-commercial reference. This material may not otherwise exist downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether at present known or later invented, except as authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

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