Coding requirements for follow ups

[nexus73]

Advertisement - Members don't see this ad

Is medical decision making a required element to meet billing level for follow up appointments? My understanding was 2 of 3 elements are required, with no specific requirement for any one element. My employer is telling me that MDM is required to be one of the two to meet a certain billing level.

 

[TexasPhysician]

This is where it gets tricky.

While the exact wording may be in your favor, documenting only to obtain higher reimbursement is looked down upon and will bring audits.

 

[cookymonster]

This unfortunately is how many organizations choose to ensure that "medical necessity" for a certain billing code is met, despite that medical necessity and medical decision-making are not the same concept. Medical necessity refers to the lowest level of services you need to provide for an encounter and is supposed to prevent you from billing higher codes simply by documenting as much history and doing as extensive an exam as you can, but there are no concrete guidelines for judging this as we have for components of E&M coding. Medical decision-making is the closest approximation we have, and using this to drive E&M coding is a way to prevent audits for not meeting medical necessity.

On the other hand, it's not too hard to imagine a scenario, such as a crisis, where detailed history-taking and a full mental status evaluation is indicated, but for which the medical decision-making turns out to be low-moderate (i.e. someone with Adjustment D/O whom you discharge with a safety plan and referral). So I guess if you have a case like that you can argue that a higher E&M code is justified and see if the coders buy in.

 

[Guyton]

You are correct. 99212-99215 CPT codes require appropriate documentation for TWO out of THREE of the following : History, Exam, and/or Medical Decision Making.

 

[DD214_DOC]

How do you code for a parent providing an unwanted wealth of detailed history not relevant to the clinical encounter? I'm constantly having discussions with parents regarding problematic behaviors and their treatment despite the child having an established therapist, who is obviously not doing their job.

On a more serious note, am I able to code for a psychotherapy add-on if the patient also has an appointment with their regular therapist later that day, in the same clinic? My gut says, "no", and that I wasted 30 minutes of my time, at least from a billing perspective.

 

[nexus73]

Anyone have a good resource for "medical necessity". It seems to me like inpatient level 1 followup should almost never be billed unless you are writing extremely basic notes. The criteria for level 2 followup is so low, I would say almost all patient notes will meet this criteria based on history and examination.

A level 2 history requires only 1 element in History (eg "Patient depressed, rated 7/10 severity) and 6 bullets in mental status examination (easily met by basic MSE in my opinion; eg General appearance, speech, thought process, thought content, mood/affect, judgment/insight...done...I don't see a much more basic mental status than that).

Ultimately, it seems like billers/employer just want me to be hitting the medicare averages for each code and care less about the specific criteria, though I don't think they will say that directly.

Another issue I've run in to is they don't want to count Insomnia as a problem, even when the management of that diagnosis is separate from the other inpatient diagnoses. Another example, is not wanting to count medical issues, like treating UTI, or adjusting HTN meds as problems for the medical decision making criteria. Does anyone know if insomnia is specifically carved out if it is secondary to depression or anxiety?

 

[smalltownpsych]

How do you code for a parent providing an unwanted wealth of detailed history not relevant to the clinical encounter? I'm constantly having discussions with parents regarding problematic behaviors and their treatment despite the child having an established therapist, who is obviously not doing their job.

On a more serious note, am I able to code for a psychotherapy add-on if the patient also has an appointment with their regular therapist later that day, in the same clinic? My gut says, "no", and that I wasted 30 minutes of my time, at least from a billing perspective.

Actually, you could code the interactive complexity add-on for the difficult parent. It isn't much financially, but it helps psychologically every time I check that little box. As far as coding therapy for same day, depends on insurance. You can always bill for it so long as you did it. Whether or not it gets paid is a different story. Heck, maybe that lame therapist's charge would be the one that gets denied.

 

[michaelrack]

Anyone have a good resource for "medical necessity". It seems to me like inpatient level 1 followup should almost never be billed unless you are writing extremely basic notes. The criteria for level 2 followup is so low, I would say almost all patient notes will meet this criteria based on history and examination.

A level 2 history requires only 1 element in History (eg "Patient depressed, rated 7/10 severity) and 6 bullets in mental status examination (easily met by basic MSE in my opinion; eg General appearance, speech, thought process, thought content, mood/affect, judgment/insight...done...I don't see a much more basic mental status than that).

A level 2 inpt f/u (99232) history requires 1-3 HPI + 1 ROS. it's easier to use history rather than exam to qualify for level 2 (+ mDM)

This should qualify for 99232: " F/u MDD: Tolerating meds, appetite decreased, denies SI but still depressed, cont prozac and add remeron 7.5 mg qhs"

the key for level 2 inpt f/u is documenting 1 RoS. I don't see any problem with using sleep/insomnia as ros

 

[nexus73]

A level 2 inpt f/u (99232) history requires 1-3 HPI + 1 ROS. it's easier to use history rather than exam to qualify for level 2 (+ mDM)

This should qualify for 99232: " F/u MDD: Tolerating meds, appetite decreased, denies SI but still depressed, cont prozac and add remeron 7.5 mg qhs"

the key for level 2 inpt f/u is documenting 1 RoS. I don't see any problem with using sleep/insomnia as ros

Is your example just the history or the entire note?

 

[nexus73]

A level 2 inpt f/u (99232) history requires 1-3 HPI + 1 ROS. it's easier to use history rather than exam to qualify for level 2 (+ mDM)

This should qualify for 99232: " F/u MDD: Tolerating meds, appetite decreased, denies SI but still depressed, cont prozac and add remeron 7.5 mg qhs"

the key for level 2 inpt f/u is documenting 1 RoS. I don't see any problem with using sleep/insomnia as ros

How about using insomnia as a problem to count towards MDM, assuming you're treating the insomnia?

 

[michaelrack]

Is your example just the history or the entire note?

I may have made it a little too short, this should qualify (entire note):

" F/u MDD and insomnia: Tolerating meds, appetite decreased, denies SI but still depressed, cont prozac and add remeron 7.5 mg qhs (for worsening insomnia and mood)"

I think it is fine to use insomnia towards MDM and could also use in for ROS (example, partial note: " ROS + for insomnia; this appears to represent primary insomnia and will start ambien")