Author Topic: Coding 99214 vs 99213 for a sick visit  (Read 4561 times)

rgcolumbus

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Coding 99214 vs 99213 for a sick visit
« on: September 18, 2012, 09:09:55 AM »
This year, the pediatric provider that my two children use has started coding all sick visits at 99214.  They used to code them all at 99213.  When I inquired about the change, they told me that they had been under-coding in the past.  I am having a hard time accepting this because the family doctor that I go to codes everything at 99213.  I asked my insurance company to review the records for one of my child's visits and they said that the records met the criteria for a 99214.  I get the feeling that my pediatric provider is making the exam and history complex enough to satisfy the requirements of 99214 even though it may not really be medically necessary.  For instance, one of my children went in to get a cough checked out.  The diagnosis was 'cough' and there was no treatment plan other than to bring her back if it got worse.  She has no medical conditions and is not on any medication.  Yet this was coded as 99214.  Since I have a high deductible health plan, this directly impacts my out of pocket cost.  What should I do?  Am I making too big a deal out of it?  Thanks.

PMRNC

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #1 on: September 18, 2012, 09:54:38 AM »
Right off the bat any provider automatically labeling all sick visits 99214 sends a red flag up to me since each CPT E/M Criteria has to be met within the medical record, which leads me to believe their documentation may not be up to par at all.   I Would contact your carrier and let them know your findings, they will in turn investigate, request records, if they believe they have an issue with that provider on other patient's they will conduct a larger investigation with a red flag on the provider and possible audit. When you said the provider started coding ALL sick visits as 99214, was that something you seen in writing or was told by the provider? That is something you must let the carrier know.   Not only does reporting this help you, but it saves the insurance company and possibly other patient's the added expenses and ultimately this type of potential fraud is part of the big picture on the rising healthcare costs and premiums.  Oh and you can do this under the radar, the carrier will not list it as a complaint, but rather internally investigate it for you.
Linda Walker
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rgcolumbus

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #2 on: September 18, 2012, 11:09:19 AM »
Thanks Linda.  The provider did not tell me that they are coding all sick visits as 99214, I made this analysis myself by looking at past claims.  In 2011, my children had a total of 7 sick visits.  Six were coded 99213 and one was 99214.  In 2012, my children have had 11 sick visits so far.  Nine have been coded 99214, one was 99213 and one was 99215.  The 99215 is what really caught my attention and got me looking into this.  When I asked the provider about it, they did an audit and said the 99215 was an error and should be 99214.  They also said one of the 99214's should have been 99213.  When I asked why the coding had changed from mostly 99213 in 2011 to mostly 99214 in 2012, they told me that five of the 99213 visits in 2011 had been under-coded.

I tried to get some help from my carrier (Anthem) on this and they have been less than helpful.  They are only interested in looking at one claim at a time, not the overall situation.  So I picked one of the 99214 visits that seemed especially simple and asked them to review it.  It took a total of three months for Anthem to get the records into their system and sent to the review department.  I faxed them twice and then finally mailed them.  I know the provider faxed them a couple times as well.  Anyway, Anthem came back and said that the provider had met the criteria for billing 99214.  They said they do not challenge the provider as long as the records support the billing code.  They said if I disagree with the level of service provided, that is my issue to take up with the provider.  From what I have read online, the provider can pretty easily give a detailed exam and get a detailed history and bill that as 99214, even if there is no medical decision making (since only 2 of the 3 criteria are needed).  I think that is what may be happening here.  Not sure what to do next since we really do like the doctor himself.

PMRNC

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #3 on: September 18, 2012, 11:55:39 AM »
That irks me when we go to an insurance company and hand them a case of fraud and abuse on a silver platter and they ignore it.   Since you do like the provider why don't you try to confront him with all the information directly, NOT biller, but the provider himself? There is always the possibility he isn't aware of what the billing dept/person is doing.
Linda Walker
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rgcolumbus

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #4 on: September 18, 2012, 02:27:46 PM »
I am told the doctor is aware, but I have not sat down with him personally to discuss.  I'm setting up a meeting with the coder to discuss in person.  I'll let you know if we can come to some agreement.  Is there a place I can find recent national data for typical code utilization to support my argument?  i.e. is 99213 used 70% of the time and 99214 used 30% of the time?
« Last Edit: September 18, 2012, 02:29:41 PM by rgcolumbus »

dekenn

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #5 on: September 19, 2012, 09:32:49 AM »
My goodness! Let's convict him now! Why is it assumed this is a case of fraud and abuse? The patient states that she complained to the insurance company, they reviewed it, and determined that 99214 was appropriately billed.......

DMK

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #6 on: September 19, 2012, 10:14:24 AM »
I hesitated to jump in, but if the kid was sick, and you're happy with the doctor's care, and the ins. co. reviewed and it was appropriately billed, pay your bill!  We're talking CARE, not $$$.

rgcolumbus

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #7 on: September 19, 2012, 12:55:29 PM »
The bill has long been paid.  The issue I have is not because of a single visit, it is the overall pattern. 10 out of 11 visits so far this year have been billed at 99214.  Is that normal?  My kids don't have chronic conditions or complex medical needs.  These are visits for seasonal colds or bronchitis.  I need some convincing that 99214 services are really justified this often.  The other aspect is that every time I see my family doctor, they bill 99213.   And, the pediatric provider used to bill 99213.  So all this together makes me feel like something is wrong.  The $$$ add up when your kids see the doctor 10-15 times per year.

DMK

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #8 on: September 19, 2012, 01:18:12 PM »
I'm not sure if you have access to the CPT book so maybe this will help define each situation:

99213 Expanded problem focused history
          Expanded problem focused examination
          Medical decision making of LOW complexity
          (Condition is of low to moderate severity, although the code is NOT time based, this would typically be  a 15 minute appointment)

99214 Detailed history
          Detailed examination
          Medical decision making of MODERATE complexity
          (Condition is of moderate to high severity, although the code is NOT time based, this would typically be a 25 minute appointment)

99215 Comprehensive history
          Comprehensive examination
          Medical decision making of HIGH complexity
          ( Condition is of moderate to high severity, although the code is NOT time based, this would typically be a 40 minute appointment)

A cold, 99213, bronchitis 99214, broken arm from an accident 99215. (Examples)  When tests are ordered it's higher complexity.

I'm not sure of your background or medical experience, so I hope these definitions will help to reconcile the billed codes with the services you received.

Also, undercoding is just as bad as overcoding.  Medicare will slap you hard for not billing appropriately.

rgcolumbus

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #9 on: September 19, 2012, 03:52:47 PM »
Thanks.  I do not have a medical background, but I have read quite a bit about these particular codes during this process.  The definitions and guidelines are pretty easy to find online.

For the example that I sent to the insurance company for review, the chief complaint was: 'cough, congestion'.  The Assessment was 'cough'.  There was no medication prescribed.  The provider gave me the medical records.  For this visit, they classified the history as detailed, the exam as comprehensive, and the decision making as low.  Since 2 of the 3 criteria are needed, this met the 99214 level.  Since the records back up the detailed history and the comprehensive exam, the insurance company is OK with it.

So, it makes me question if a detailed history/comprehensive examination is a reasonable and necessary for these symptoms.

DMK

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #10 on: September 19, 2012, 04:57:44 PM »
I see your point, and understand the concern.  However, considering the uptick in whooping cough, he was probably doing his due diligence to make certain the "cough" wasn't something more serious.  For adult care, we probably know if we're sick or REALLY sick so you could better determine 99213 or 99214.

rgcolumbus

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #11 on: September 20, 2012, 11:57:22 AM »
Well, I sat down with the coder and she went through several scenarios.  Basically, there are certain history items they always ask.  The number of items classifies the history as detailed.  The exam is always comprehensive since they are dealing with pediatric care and they don't want to miss something.  Since these two meet the guidelines for 99214, I pretty much have to accept that they will always be billing this.

I would love to see some statistics for pediatric care and how often each code is used.  This would give me a better understanding if I am being treated fairly.

RichardP

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #12 on: September 21, 2012, 11:15:11 AM »
Maam, you are the parent.  You know your child.  You state that it is only a cough.  Yet you take the child to the doctor.  The doctor knows what I just stated.  The doctor knows you wouldn't be in his office if you were convinced it was just a cough.  The doctor thinks the same thing you are thinking - is this something more than just a cough?  You are not paying to get the cough treated.  You are paying for the assurance that it is nothing more than just a cough.

Determining that a cough is indeed just a cough may be simple.  Determining that a cough is not something more than just a cough is more complex.  That is why the higher coding and the higher charge.

rgcolumbus

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #13 on: September 21, 2012, 11:26:34 AM »
Thanks.  So if that is what a typical 99214 visit looks like, what does a typical 99213 look like?

RichardP

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Re: Coding 99214 vs 99213 for a sick visit
« Reply #14 on: September 21, 2012, 11:43:49 PM »
Assume the cough has been determined to be caused by nothing more than post-nasal drip. Child is an established patient.  You take child back to doctor because he is getting a sore throat from coughing.  Doctor verifies that throat is sore and suggest some course of action to address the sore throat.  Will likely request to see the child in the near future to verify that the sore throat is getting better and not worse.

If you want to educate yourself a bit, you might check out these links.  If you are really curious, check out the home page as well.

http://emuniversity.com/Level3EstablishedOfficePatient.html
http://emuniversity.com/ClinicialExample99213.html
http://emuniversity.com/Page7.html

http://emuniversity.com/index.html