According to this article, David is correct to be concerned about the excessive use of the 99215 code: Coding Better for Better Reimbursement (http://www.aafp.org/fpm/20030100/29codi.html) "Beware of 99215s. You shouldn't be coding many 99215s because it is rare that an established patient will come in for a visit that requires a comprehensive history or a comprehensive examination - and a patient who does require these things is usually sick enough for hospital admission instead. 99215 is not the code to use for an annual physical examination. There's a separate set of codes that relate to the annual physical examination. Be very cautious about using 99215 because of the issue of medical necessity and the audit process. It's not worth the hassle." Even if you appropriately code every patient as 99215, the insurers usually expect a bell curve pattern for E&M coding with the bulk being 99213s. (See graphic: http://www.aafp.org/fpm/20030100/29codi_f2.gif). Anything that doesn't fit this pattern may trigger an audit. I believe Gordon may have experienced something like that? But as long as you are able to document that the criteria for appropriate coding were met, it should be justified. I'm not a coding expert, but I don't think it is considered appropriate for someone to come in with a minor problem, like a URI, do a comprehensive history and physical exam, and charge for a 99215 because the severity of the problem didn't REQUIRE that intense of a workup. Appropriate alternatives to 99215s would be: 1) coding for preventive care services (like a physical): Making Sense of Preventive Medicine Coding (http://www.aafp.org/fpm/20040400/49maki.html) 2) coding on the basis of time and documenting start and stop time in the progress note: Time Is of the Essence: Coding on the Basis of Time for Physician Services (http://www.aafp.org/fpm/20030600/27time.html) "For visits that involve more than 50 percent counseling or coordination of care, time can determine the level of coding. For example, if a 30-minute office visit with an established patient involved more than 15 minutes of counseling and coordination of care, you could automatically code the visit as a 99214." 3) code as a 99214: How to Get All the 99214s You Deserve (http://www.aafp.org/fpm/20031000/31howt.html) Perhaps Michelle could run these by a medical biller she knows and sees how they would code it and why. As I am finding out, medical coding is definitely confusing! (but not impossible) Gary Seto South Pasadena, CA On Aug 16, 2004, at 6:04 AM, David Brock DO wrote: Are you really coding many return visits as 99215’s? I am still very hesitant to use a 99215/99205 code ever. Most HMO’s here make you automatically send the notes with those codes. I was under the impression that a 99215 was a pt that basically needed to be admitted right away to the hospital, almost an office emergency type of patient visit. Are others coding any 99215/99205 visits? I am also surprised that any HMO’s are paying you for the extended service codes. David Brock, D.O. London, Ohio -----Original Message----- From: Michelle Eads [mailto:michelle.eads@worldnet.att.net] Sent: Saturday, August 14, 2004 1:33 PM To: Group Gordon's Subject: [Practiceimprovement1] practice data answers Howdy Gang, I have received some questions on my practice data, and would like to share my answers with you. First question was how I use my staff. I have one MA, who does front desk duties (answers the phone, scheduling, collects copays, copies insurance card and drivers license, verifies eligibility if needed), nursing duties (takes vitals, pulls up the appropriate encounter form, administers vaccines, does CLIA-waived labs, calls pts back with results) and billing duties (enters EOBs, allocates payments to pt account). I do the filing, chasing AR, and printing monthly statements in addition to the usual doc stuff. Second was on reimbursement. I haven’t calculated my avg reimbursement per encounter. Bear in mind that the revenue includes the $50/person annual fee to cover the unlimited email and phone care, and filing out forms and prescriptions, as indicated in my practice data info. I am contracted with 3 insurance companies (Kaiser, United HealthCare, and Pacificare). Because most of my appointments are lengthy (45-60mins long), the vast majority of my appts are a 99215. For the three ins companies, HMO portion (some have PPO too), I get $149 on average for 99215. For physicals (99396 for instance), I get $140 on average. I have a fair amount (25-30% I would guess) of people that see me out of network, and thus get my ‘full price’ paid, which is a little higher. I use the code for prolonged services (number escapes, me – I have it at the office) when the appt is >30mins longer than expected for the complexity of the visit (may have this 1-2x a week). This is often reimbursed well, from $60-$140, in addition to the 99214/5. Hope this helps clarify things. Michelle A. Eads, M.D. Pinnacle Family Medicine, PLLC (719) 687-8752 phone (719) 687-8753 fax P.O. Box 7275 Woodland Park, CO 80863 Yahoo! Groups Sponsor ADVERTISEMENT Yahoo! Groups Links • To visit your group on the web, go to: http://groups.yahoo.com/group/Practiceimprovement1/ • To unsubscribe from this group, send an email to: Practiceimprovement1-unsubscribe@yahoogroups.com • Your use of Yahoo! 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