Sicker patients do not always mean higher MDM.
If your physician bills a lot of high-level office visits, he may be in danger of an audit, which may not be a cause of worry if his documentation justifies his code choices.
“Some doctors think that their patients are sicker than others’; as such they feel they are justified using more 99215s, when in fact that may not be the case,” according to Crystal S. Reeves, CPC, CPC-H, consultant with Coker Group in Alpharetta, Ga. “The CPT manual outlines the requirements of the evaluation/management codes, there’re clinical examples in the back of CPT, and CMS publishes a Table of Risk that can guide you, so use all of those resources to find out whether you are billing properly,” she says.
Training is important: If you advise your doctor that he’s overbilling the high-level codes and he says, “But all of our patients are in actuality sick,” show the doctor CMS’s Table of Risk, “which can be an eye opener for doctor,” says Reeves.
According to Reeves, when it comes to MDM for high-level evaluation/management services, “look for how many diagnoses or management options the physician is treating. “If a patient presents with a brain tumor and is chemotherapy but is faring well, his condition may eventually be terminal however this visit may not qualify for a level five. However if the patient has COPD, hypertension, degenerative disc disease, pneumonia, and diabetes, there’ll be more data to review, which may qualify for a higher MDM level.”
You should make diagnosis coding a priority: If your claim does not convey the status or complexity of the condition, an auditor will not be able to infer it, Stephanie L. Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y says. “The best option to do this is to report your diagnosis codes to the highest level of specificity.”
If a diagnosis code is not listed on your superbill, do a research to find it rather than just using one that you do to list on your encounter form.
“Certain diagnoses may not be listed on a physician’s superbill; as such the physician may just circle the closest unspecified code,” says Fiedler. For example, a physician might circle the standard controlled diabetes code on a superbill as it is there, “however any time there are renal, peripheral vascular, or ophthalmic complications, those are the ones they have to go back to the coding book for and most of the time, they don’t,” she says.
“Minus the more specific code, the doctor is not conveying the acuity of what he is doing, so the diagnosis may not support the claim.”