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osagiv

Registered:
Posts: 1
Reply with quote  #1 
Hello I am a cardiovascular specialists who treats a fairly sick patient population.
I have a question on level 5 f/u 99215

I have a lot of patient that qualify for level 5 f/u visits as i review alot of new data with them and they have multiple medical problems. I do charge a fair amount of 99215 because of it but my coder is telling me that even if I have a full exam or full HPI and more than 4 diagnosis and greater than 4 points on the data , I still cant charge a level 5, despite the CMS tool that states that 2/3 categories of risk, data and problems are required for level 5 follow-up

She says risk ALWAYS has to be there? is this correct? 
IN that case, wouldnt the CMS tool state that risk must be ONE of the 2 categories required for level 5 MDM ?

Thank you
WENDYR1

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Posts: 7
Reply with quote  #2 
You are correct, as long as MDM meets 2 of the 3 categories (A and B) Risk (C) is not necessary.
Unregistered
Reply with quote  #3 
CMS states "Medical necessity of a service is the overarching criterion for payment in addtion to the individaul requirements of a CPT code.  It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.  The volume of documentation should not be the primary influence upon which a specific level of service is billed.  Documentation should support the level of service reported.  The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

Our organization requires that MDM be one of the 2 when 2 of 3 are required by CPT.  They feel this is the mental work of the physician and ties the history and physicial together in determining the problem and the plan for the care of the patient.
Unregistered
Reply with quote  #4 
Thank you all for the responses but I am still not clear as to the correct answer:

I am using always MDM as the 2/3 criteria but within the MDM , if I have 4 diagnosis and 4 data points, and moderate risk , can I still charge a level 5 assuming hpi or PE is complete?

My coder keeps downgrading me from 99215 to 99214 because of she says high risk within the MDM has to be there but then i show her the cms tool and she still questions me ?

I do manage all the patients diagnosis even if they are stable.


Quote:
Originally Posted by Unregistered
CMS states "Medical necessity of a service is the overarching criterion for payment in addtion to the individaul requirements of a CPT code.  It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.  The volume of documentation should not be the primary influence upon which a specific level of service is billed.  Documentation should support the level of service reported.  The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."

Our organization requires that MDM be one of the 2 when 2 of 3 are required by CPT.  They feel this is the mental work of the physician and ties the history and physicial together in determining the problem and the plan for the care of the patient.
Unregistered
Reply with quote  #5 
To me that what be a 99215.  What may be the reasoning for the down coding is how often you are putting out 99215's.  Too many of these will trigger an audit.  Another thing to look at is time based coding.  Even if it was a 99214 and you meet the time based criteria and documentation you can jump the code up
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