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HOW TO USE CPT CODES EFFECTIVELY FOR OFFICE VISITS
DON SELF & ASSOCIATES
In the past 15 years, the art of coding medical claims has gone from being as easy as taking a blood pressure reading to as difficult as finding a cure for HIV. Things use to be so simple, but now with more than 7,000 AMA CPT codes, hundreds of HCPCS codes and tens of thousands of ICD9 code combinations, it almost takes a college degree to code an insurance or Medicare claim properly. Of course, the degree doesn't mean much, because as soon as you learn it, they change the codes, formatting, modifiers and criteria.
While this article is not intended to solve all of your coding problems, or completely define the complicated and sometimes ridiculous CPT coding system, it is designed to give you a few things to think about in your practice. The number one rule when coding or filing any insurance claim WAS:
IF IT'S NOT DOCUMENTED - IT WASN'T DONE
Now, the number one rule has been changed. It now reads:
IF THE SERVICE AND THE MEDICAL NECESSITY ISN'T DOCUMENTED - IT WASN'T DONE
The main problem we have seen in all of the Medicare reviews, audits and "fair" hearings we have participated in, was the service was either not documented in the appropriate chart or the medical necessity for giving the service wasn't proven. Without both of these factors being shown in the chart, there is no reason to discuss coding the claim, as no claim should be filed.
Assuming that you are one of the less than 20% of physicians that ALWAYS accurately ensure your documentation meets the requirements of Medicare, Medicaid, Workers Compensation, Private Insurance and Managed Care Agencies, let's discuss a few factors to take into consideration when determining which office visit should be used on a claim.
AMA CPT procedure codes 99201 through 99205 are for use of new patient office visits.
Cpt Codes 99211 through 99215 are to be used with established patients (patients you have seen or treated within the past 3 years)
Code 99201 includes almost NO history on the new patient, and unless you plan to utilize the services of Dr. Kavorkian and commit business suicide, we do not recommend you see any new patient without obtaining a history on the patient. In today's litigious society, you cannot turn on a television without seeing some attorney saying things like "Have you been hurt? Have you been damaged? Has someone looked at you cross-eyed and caused permanent mental damage to you? Have you pulled a ligament while reaching up for a can of beans at the store? If so, give us a call and we'll sue everyone you know!!!" If you plan on seeing new patients without obtaining a history on the patient, you may as well stop reading now and cancel your subscription to your internet provider as you are gonna need that $20 a month you pay for it.
Procedure codes 99202 and 99212 are level 2 office visit codes that requires no clinical chemistry tests, a very limited examination, very limited medical decision making and a limited history on the patient. A good example would be a new patient coming into your office with a roofing nail in their foot. You are basically gonna ask a few questions, pull the nail out, clean the wound, bandage it and give the patient a tetnus injection.
Codes 99203 and 99213 are for routine office visits that may include limited clinical chemistry tests OR limited diagnostic tests, a routine examination and average medical decision making on your part. Of course, there needs to be a personal and family history performed, but it is my belief that you probably do at least this on all new patients. An example of this would probably be a patient coming in with influenza, a stomach virus, ear infection, or some routine problem that requires some lab tests, diagnostic tests or more than just limited medical decision making. The majority of your office visits will probably be coded with the level 3 codes.
Codes 99204 and 99214 should be utilized when you have to perform clinical lab services and diagnostic tests or you need to perform a pelvic exam, rectal exam, breast exam or a pap smear during the same visit. These services should include multiple diagnosis or a diagnosis that is such that complicated medical decision making and examination would be justified. We caution you against using the level 4 codes most often to increase your revenue and income as the major carriers have successfully found some physicians guilty of this.
Codes 99205 and 99215 should be used on less than 5% of your office visits, as this level of a service usually implies that the patient's condition is such that you were required to check almost every body area, function, and orafice closely. This level includes a detailed and comprehensive examination, history, complex medical decision making, multiple diagnostic and clinical chemistry tests. Basically, I heard one Hearing Officer refer to this level as the physician needing to go to his or her books in order to discover what diagnosis the patient had and how to treat it.
With these codes in mind, there are some factors that can make your practice alot of money. For instance, we have discovered a higher percentage of physicians not charging for many services they render in their office, as they were unaware they may charge for them. We have found that many practices have increased their income substantially by using.. Uh Oh - I am doing it again.
Instead of me giving it away on this free internet page, I need you to call us so that we may come out to your office, examine your coding and discover areas where you can increase your income. Drop us an email. Give us a call. If you would like, we will send you a list of references of other physicians that have utilized our services.