When do you do 99213/99203 visits?

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AmiSansNom

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I find that I rarely do 99213 follow-up visits, and I don’t think I have ever done a 99203 new patient visit. Is this normal in Hem/Onc community practice? My 99213s are probably ~10% of total visits, if that. Usually MGUS, iron deficiency anemia which has now resolved, anemia with chronic kidney disease, AML/APL/Hogkin on clinical and lab surveillance 10 years out, early stage colon cancer on clinical and lab surveillance 5 years out etc. And even for these, they frequently have another medical problem, most likely hypertension, and since their BP is measured and their meds are reviewed, I document this and say something like BP is good, continue antihypertensive regimen, or BP high, recommend measuring at home and following up with PCP, and as this is discussed, it gets added on as a second problem, and now it becomes a 99214. Is this reasonable? Just want to make sure this is what others are doing as well, or if you think I should change practice. Thank you.

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I’m of the opinion that if you’re not actively managing it, just mentioning it in your note doesn’t magically bump your complexity up. So I only talk about the things I’m willing to take responsibility for and deal with when necessary.

That said, I do about 25-30% 99213 25-30% 99215 and the rest 99214.

Most of my benign heme new consults are 99204 and most of my new solid tumors are 99205. I have probably done 3-4 99203s in the last year.

The G2211 code is a great way to buff your wRVUs without skewing towards fraud.
 
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I’m of the opinion that if you’re not actively managing it, just mentioning it in your note doesn’t magically bump your complexity up. So I only talk about the things I’m willing to take responsibility for and deal with when necessary.

That said, I do about 25-30% 99213 25-30% 99215 and the rest 99214.

Most of my benign heme new consults are 99204 and most of my new solid tumors are 99205. I have probably done 3-4 99203s in the last year.

The G2211 code is a great way to buff your wRVUs without skewing towards fraud.
@gutonc do you code all active chemo patients as level 4 or 5?
I’ve heard you can do 5, as long as their doing ROS and documenting that you’re monitoring for symptoms.
 
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@gutonc do you code all active chemo patients as level 4 or 5?
I’ve heard you can do 5, as long as their doing ROS and documenting that you’re monitoring for symptoms.
Almost all are 4s or 5s.
1. Cancer getting chemo
2. CINV
3. Chemo induced diarrhea
4. Pancytopenia
5. Random other chemo SE

You can probably get at least 3 of these out of 75% of your treatment patients and that's a 99215 every day. ROS is a waste on it's own, just document what matters.
 
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Almost all are 4s or 5s.
1. Cancer getting chemo
2. CINV
3. Chemo induced diarrhea
4. Pancytopenia
5. Random other chemo SE

You can probably get at least 3 of these out of 75% of your treatment patients and that's a 99215 every day. ROS is a waste on it's own, just document what matters.
I ask because I do level 5 for all patients across the board.
Document something like labs reviewed, within parameters. Continue intensive monitoring for toxicity related to treatment.

I asked our billing and they said it should be fine…. But I don’t know how much they actually know.

I now add the G2211 code too.
 
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I ask because I do level 5 for all patients across the board.
Document something like labs reviewed, within parameters. Continue intensive monitoring for toxicity related to treatment.

I asked our billing and they said it should be fine…. But I don’t know how much they actually know.

I now add the G2211 code too.
🤷‍♂️
You do you boo. Not sure I believe your coders, but as long as CMS lets you get away with it, I guess make hay while the sun shines.
 
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I ask because I do level 5 for all patients across the board.
Document something like labs reviewed, within parameters. Continue intensive monitoring for toxicity related to treatment.

I asked our billing and they said it should be fine…. But I don’t know how much they actually know.

I now add the G2211 code too.
Thank you. What about oral drugs, for example, early stage HR positive breast on adjuvant endocrine therapy, who you presumably see every few months? Or prostate on ADT every 3 months? Is 9915 justified for those or do you tend to do 99214 for those?
 
I’m of the opinion that if you’re not actively managing it, just mentioning it in your note doesn’t magically bump your complexity up. So I only talk about the things I’m willing to take responsibility for and deal with when necessary.

That said, I do about 25-30% 99213 25-30% 99215 and the rest 99214.

Most of my benign heme new consults are 99204 and most of my new solid tumors are 99205. I have probably done 3-4 99203s in the last year.

The G2211 code is a great way to buff your wRVUs without skewing towards fraud.
Thank you. I didn’t think 25-30% would be 99213s. Wonder if this high a % is commonly seen across the board. Could you give me some info about the G2211? I was unaware of its existence until now.
 
Thank you. What about oral drugs, for example, early stage HR positive breast on adjuvant endocrine therapy, who you presumably see every few months? Or prostate on ADT every 3 months? Is 9915 justified for those or do you tend to do 99214 for those?
I do 99214 for those, and add a sprinkle of "monitoring" phrases in there. For example, patients on ADT I say things like monitor weight, monitor for cardiac symptoms, monitor hot flashes/consider effexor but patient declines at the moment to beef up the note. Not sure if all of that matters or not when coding/billing though. I just do it to make myself feel better lol
 
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I ask because I do level 5 for all patients across the board.
Document something like labs reviewed, within parameters. Continue intensive monitoring for toxicity related to treatment.

I asked our billing and they said it should be fine…. But I don’t know how much they actually know.

I now add the G2211 code too.
My billing department said the same thing. My friends in another institution also bill level 5 across the board for chemo w/ no issues ever.
 
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Thank you. I didn’t think 25-30% would be 99213s. Wonder if this high a % is commonly seen across the board. Could you give me some info about the G2211? I was unaware of its existence until now.
I see literally everything out here in the woods. The vast majority of my benign heme referrals could be managed by a moderately competent FM intern in July, but they still keep sending them to me. Those are 99204 and then hopefully just one or two 99213 follow ups. But that's easily half of my referral volume.
 
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I do 99214 for those, and add a sprinkle of "monitoring" phrases in there. For example, patients on ADT I say things like monitor weight, monitor for cardiac symptoms, monitor hot flashes/consider effexor but patient declines at the moment to beef up the note. Not sure if all of that matters or not when coding/billing though. I just do it to make myself feel better lol
Me too. Early ER+ BC on AI is a level 4 or 5 easily (Cancer/Bones/Hot Flashes/Arthralgias). ADT for BCR prostate is a level 4 (Cancer/Bones) and is an easy level 5 when you add enza or abi.
 
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This is very helpful. Some of my colleagues—or our coding and billing folks—are not as well-versed in oncology coding or billing.

I'm actively reducing my benign hematology panel to focus more on malignant hematology and solid oncology care. I’ve been using level 3 coding for benign hematology patients during their last follow-up with me.

The coding suggestions above align with my prior coding practices. However, I've now begun coding at level 4, even when cases warrant level 5, to avoid appearing as an outlier.

As a new and busy attending, I have many patients in the active treatment phase rather than on surveillance, and I’m not sure our coding compliance team understands this dynamic.
 
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Any cancer not on therapy, on surveillance, no interpretation of imaging and no change in medications - social visits essentially will be 99213.
 
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I do 99213 for heme visits where their counts are mild and no change in medication or side effects from their iron/other medicine.
It's rare I do them for onc visits because even surveillance I'm reviewing scan or doing a thorough physical exam.
 
I do 99213 for heme visits where their counts are mild and no change in medication or side effects from their iron/other medicine.
It's rare I do them for onc visits because even surveillance I'm reviewing scan or doing a thorough physical exam.
Two questions (actually one..and a comment:
1. Why?
2. Physical exam no longer has any bearing on billing complexity.

I mean, I put a stethoscope to the front and back of the chest for a few seconds for show since people seem to think that means I'm a good doctor, and will look at something somebody's worried about (it's always a mole and I always tell them to see their dermatologist). I check axillary LNs in breast cancer patients but don't bother with a breast exam (that's what mammograms are for) and I'll do a more thorough LN exam in lymphoma patients. But the physical exam borders on worthless other than focused on a specific complaint, even then, it's just barely above worthless.
 
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Two questions (actually one..and a comment:
1. Why?
2. Physical exam no longer has any bearing on billing complexity.

I mean, I put a stethoscope to the front and back of the chest for a few seconds for show since people seem to think that means I'm a good doctor, and will look at something somebody's worried about (it's always a mole and I always tell them to see their dermatologist). I check axillary LNs in breast cancer patients but don't bother with a breast exam (that's what mammograms are for) and I'll do a more thorough LN exam in lymphoma patients. But the physical exam borders on worthless other than focused on a specific complaint, even then, it's just barely above worthless.
Do you think not doing (or not documenting) a thorough exam is a problem from a med mal perspective?

For example, you see breast cancer patient for endocrine therapy follow up, next mammo not for 6 months, don't examine breast and then in breast recurrence is found on mammogram and you are sued for not detecting it on exam prior to mammo?

I really don't have a feel for the med mal climate in solid oncology but feel nervous when thinking about independent practice.

The corollary of this question is I feel my breast exam skills are poor and planning on community practice. It has been difficult to get a lot of quality reps as a male fellow in breast clinic
 
Do you think not doing (or not documenting) a thorough exam is a problem from a med mal perspective?

For example, you see breast cancer patient for endocrine therapy follow up, next mammo not for 6 months, don't examine breast and then in breast recurrence is found on mammogram and you are sued for not detecting it on exam prior to mammo?

I really don't have a feel for the med mal climate in solid oncology but feel nervous when thinking about independent practice.

The corollary of this question is I feel my breast exam skills are poor and planning on community practice. It has been difficult to get a lot of quality reps as a male fellow in breast clinic
I don't disagree for med mal/CYA purposes although I'm not sure how much "exam normal" will save you if there is a bad outcome.

I do disagree with the breast exam for surveillance as anything more than theater, personally. I'd be interested to see if there was any studies looking at it, but I bet it'd be a pretty biased study as it would have been run by breast Oncologists. I definitely see the purpose of performing routine breast exam for those on treatment.
 
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I don't disagree for med mal/CYA purposes although I'm not sure how much "exam normal" will save you if there is a bad outcome.

I do disagree with the breast exam for surveillance as anything more than theater, personally. I'd be interested to see if there was any studies looking at it, but I bet it'd be a pretty biased study as it would have been run by breast Oncologists. I definitely see the purpose of performing routine breast exam for those on treatment.
I don't have it in front of me, and I don't feel like looking it up, but my fellowship breast cancer mentor is the person who taught me the folly of a breast exam as anything other than theater (except maybe in cases of neoadjuvant treatment). He showed me a study that showed that CBE by breast surgeons identified roughly 50% of mammographically diagnosed breast cancers. For "gen pop" it's closer to 30%.

If I'm giving neoadjuvant therapy to someone, I'll do a CBE at the beginning and if the mass is palpable (I'd estimate 25-30% are), I'll do another exam halfway through planned treatment.

If there's a specific complaint about a specific symptom or a physical sign pointing you somewhere, then yes, you should examine it. But in general, a full physical exam is theater.
 
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For example, you see breast cancer patient for endocrine therapy follow up, next mammo not for 6 months, don't examine breast and then in breast recurrence is found on mammogram and you are sued for not detecting it on exam prior to mammo?
By this logic, you should be doing a CBE, and a rectal exam and a pelvic and a full body skin exam...and...and on literally anyone you see, for any reason.
 
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Since we're on the topic, what about rectal exam for locally advanced rectal cancer? My fellowship mentor did it every visit, especially during TNT. I have been doing it before starting TNT, after chemoRT part of TNT, and after TNT. Thoughts on if this needs to be more routine or can omit?
 
Since we're on the topic, what about rectal exam for locally advanced rectal cancer? My fellowship mentor did it every visit, especially during TNT. I have been doing it before starting TNT, after chemoRT part of TNT, and after TNT. Thoughts on if this needs to be more routine or can omit?
I’ve never done a rectal for cancer…
 
Two questions (actually one..and a comment:
1. Why?
2. Physical exam no longer has any bearing on billing complexity.

I mean, I put a stethoscope to the front and back of the chest for a few seconds for show since people seem to think that means I'm a good doctor, and will look at something somebody's worried about (it's always a mole and I always tell them to see their dermatologist). I check axillary LNs in breast cancer patients but don't bother with a breast exam (that's what mammograms are for) and I'll do a more thorough LN exam in lymphoma patients. But the physical exam borders on worthless other than focused on a specific complaint, even then, it's just barely above worthless.
No I know PE doesn't factor directly into MDM, but by the time I do the breast exam lymph exam catch up on past few months of their hx or life and document I hit the 30 minutes for a level 4.

"Since we're on the topic, what about rectal exam for locally advanced rectal cancer? My fellowship mentor did it every visit, especially during TNT. I have been doing it before starting TNT, after chemoRT part of TNT, and after TNT. Thoughts on if this needs to be more routine or can omit?"


I would never do a rectal exam, that hurts and I would only use MRI for objective decision making.
 
No I know PE doesn't factor directly into MDM, but by the time I do the breast exam lymph exam catch up on past few months of their hx or life and document I hit the 30 minutes for a level 4.

"Since we're on the topic, what about rectal exam for locally advanced rectal cancer? My fellowship mentor did it every visit, especially during TNT. I have been doing it before starting TNT, after chemoRT part of TNT, and after TNT. Thoughts on if this needs to be more routine or can omit?"


I would never do a rectal exam, that hurts and I would only use MRI for objective decision making.
 
I’ve never done a rectal for cancer…

No I know PE doesn't factor directly into MDM, but by the time I do the breast exam lymph exam catch up on past few months of their hx or life and document I hit the 30 minutes for a level 4.

"Since we're on the topic, what about rectal exam for locally advanced rectal cancer? My fellowship mentor did it every visit, especially during TNT. I have been doing it before starting TNT, after chemoRT part of TNT, and after TNT. Thoughts on if this needs to be more routine or can omit?"


I would never do a rectal exam, that hurts and I would only use MRI for objective decision making.

Interesting. My fellowship GI doc was adamant that rectal exams need to be performed for rectal cancer. Clinically, I don't really care much for it but I just wonder from medical-legal standpoint if it's necessary
 
Interesting. My fellowship GI doc was adamant that rectal exams need to be performed for rectal cancer. Clinically, I don't really care much for it but I just wonder from medical-legal standpoint if it's necessary
All of my rectal and anal cancer patients have both a rad onc and a colorectal surgeon who are putting fingers up their butts on the reg...I tell them that one more finger up their butt isn't going to change anything.

And what would you change based on an exam during treatment? Somebody getting radiation is going to have "growth" of their tumor during treatment due to proctitis and edema.

I try not to do tests (and this includes physical exam) that aren't going to impact my management. And this is definitely one of them.

ETA: There's a lot of dogma in medicine that is passed down from generation to generation as received wisdom with no basis in fact...or at least not any fact from this century.
 
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Since we're on the topic, what about rectal exam for locally advanced rectal cancer? My fellowship mentor did it every visit, especially during TNT. I have been doing it before starting TNT, after chemoRT part of TNT, and after TNT. Thoughts on if this needs to be more routine or can omit?

Im Not No Way GIF
 
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Have never done a rectal during my fellowship and never plan to do one. But I think that for anal cancers, we're stuck with doing the exams.
 
🤷‍♂️
You do you boo. Not sure I believe your coders, but as long as CMS lets you get away with it, I guess make hay while the sun shines.

Yeah, billing all 5s is a great way to get the attention of CMS (and not in a good way).

As a rheumatologist, my ratio is probably 10% 99213, 80% 99214, 10% 99015.
 
🤷‍♂️
You do you boo. Not sure I believe your coders, but as long as CMS lets you get away with it, I guess make hay while the sun shines.
I think most systemic therapies, targeted or otherwise, should meet the criteria for intensive monitoring (unless it's something you see >3 months apart such as Tamoxifen).

I do wonder where the line is drawn for "Acute or chronic illness or injury that poses a threat to life or bodily function."

Metastatic Breast/Lung/Whatever Cancer? Easy
Metastatic Prostate?
Myelofibrosis on treatment? Probably

CML/CLL? I don't really know on these two. I mean theoretically untreated CML does really terrible.
 
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What exactly happens if one does get audited by CMS? Let's assume cases (few to many) of overbilling by maybe a level but nothing outright fraudulent like fake patient visits or the like.
 
I think most systemic therapies, targeted or otherwise, should meet the criteria for intensive monitoring (unless it's something you see >3 months apart such as Tamoxifen).

I do wonder where the line is drawn for "Acute or chronic illness or injury that poses a threat to life or bodily function."

Metastatic Breast/Lung/Whatever Cancer? Easy
Metastatic Prostate?
Myelofibrosis on treatment? Probably

CML/CLL? I don't really know on these two. I mean theoretically untreated CML does really terrible.
CML and CLL on treatment should be level 5.

Metastatic prostate on ADT/ARPi for sure is level 5. Myelofibrosis on jakafi is definitely level 5.

It's the HR+ breast cancers on AI for past 7 years that you see q6 months that is probably level 4. IDA on IV iron I bill level 4.

The MGUS yearly follow ups are level 3. Stupid consults from NPs are all level 3.
 
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Someone please correct this assumption if it is wrong, but my understanding is that CPT codes are now based either complexity or time spent overall on encounter (patient encounter + charting, reviewing results, prep, etc.).

So if I'm the kind of person who spends a significant amount of time prepping and charting before and after encounters and most encounters would be level 4 or 5 based on time alone, would that be disputable/actionable by CMS?
 
Someone please correct this assumption if it is wrong, but my understanding is that CPT codes are now based either complexity or time spent overall on encounter (patient encounter + charting, reviewing results, prep, etc.).

So if I'm the kind of person who spends a significant amount of time prepping and charting before and after encounters and most encounters would be level 4 or 5 based on time alone, would that be disputable/actionable by CMS?
It would not be disputable as long as you document the time. Just make sure the amount of time is not adding up to some absurd sum like 20 hours.
 
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It would not be disputable as long as you document the time. Just make sure the amount of time is not adding up to some absurd sum like 20 hours.
^This. As long as you document the time, you can bill for it. Even if it's just a mild macrocytic anemia that just won't shut up and you wind up doing nothing but listening to them blather on in the exam room for 45 minutes while you finish other charts, you can bill for a 99215.
 
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^This. As long as you document the time, you can bill for it. Even if it's just a mild macrocytic anemia that just won't shut up and you wind up doing nothing but listening to them blather on in the exam room for 45 minutes while you finish other charts, you can bill for a 99215.
Shocked Cosmo Kramer GIF
 
Wait? Am I the only one who does this? We all have a few of those people who just can't be redirected no matter how hard you try. Now, instead of getting super frustrated and annoyed, I just do other charts. It's more productive than being on SDN.
 
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Wait? Am I the only one who does this? We all have a few of those people who just can't be redirected no matter how hard you try. Now, instead of getting super frustrated and annoyed, I just do other charts. It's more productive than being on SDN.
DEF do this.
 
Along the lines of billing, how often are you seeing your patients on treatment? For example:

Breast cancer on AI: q3 or q6 months?
FOLFOX patients: q2 or q4 weeks?
Prostate cancers on ARPi: monthly or q3 months?
Anyone on targeted treatments: monthly or q3 months?

Seeing them more frequently obvious is easy money. Has anyone gotten in trouble with CMS from seeing them "too frequently?" Most of my patients don't care, and they all will just listen to whatever frequency I tell them to come at. I certainly don't mind the easy copy/paste 99215s. What have you all been doing?
 
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Along the lines of billing, how often are you seeing your patients on treatment? For example:

Breast cancer on AI: q3 or q6 months?
FOLFOX patients: q2 or q4 weeks?
Prostate cancers on ARPi: monthly or q3 months?
Anyone on targeted treatments: monthly or q3 months?

Seeing them more frequently obvious is easy money. Has anyone gotten in trouble with CMS from seeing them "too frequently?" Most of my patients don't care, and they all will just listen to whatever frequency I tell them to come at. I certainly don't mind the easy copy/paste 99215s. What have you all been doing?
AI is Q6months

Prostate I usually have seen Q2m but I'm curious what others do.
 
Along the lines of billing, how often are you seeing your patients on treatment? For example:

Breast cancer on AI: q3 or q6 months?
Q3 for the first year or 2, then Q6-12 mos depending on the patient. NCCN guidelines say "1-4x/y as clinically appropriate".
FOLFOX patients: q2 or q4 weeks?
Q2. My NP and I switch off but I see them every time they get chemo. For people on weekly chemo (or 3w/4), I'll see them every 2nd or 3rd week. Always on D1 of each cycle.
Prostate cancers on ARPi: monthly or q3 months?
Monthly or Q6w for the first 3 months then Q3 mos.
Anyone on targeted treatments: monthly or q3 months?
More or less same as above, unless lab monitoring requires more frequent visits. I could just have them get labs and f/u by phone or MyChart, but if I'm going to do the work, I might as well get paid for it.

All of this assumes people are doing OK and managing things (physically and mentally) well.
Seeing them more frequently obvious is easy money. Has anyone gotten in trouble with CMS from seeing them "too frequently?" Most of my patients don't care, and they all will just listen to whatever frequency I tell them to come at. I certainly don't mind the easy copy/paste 99215s. What have you all been doing?
I don't think you're ever going to get in trouble for seeing people every time they come in for chemo.

One thing I think a lot about is the concept of time toxicity, especially in people with metastatic disease. This sometimes guides my follow up planning as much as anything.
 
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@gutonc

This is such a fantastic point - I think about time toxicity often but didn't know there was an actual term for it.
 
Along the lines of billing, how often are you seeing your patients on treatment? For example:

Breast cancer on AI: q3 or q6 months?
FOLFOX patients: q2 or q4 weeks?
Prostate cancers on ARPi: monthly or q3 months?
Anyone on targeted treatments: monthly or q3 months?

Seeing them more frequently obvious is easy money. Has anyone gotten in trouble with CMS from seeing them "too frequently?" Most of my patients don't care, and they all will just listen to whatever frequency I tell them to come at. I certainly don't mind the easy copy/paste 99215s. What have you all been doing?
Wait are all of the above 99215 based on complexity for you?
 
What are your general benchmarks for 99214 vs 99215 visits? Specific examples would be appreciated.
Do your hospital coders automatically downcode 99215 to 99214?
 
Wait are all of the above 99215 based on complexity for you?
Generally yes, I write some scary side effects in there to hopefully decrease the chances of audit. For example, if I'm giving prolia, I state something like "close monitoring for potential irreversible osteonecrosis of jaw." I have yet to be audited
 
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Generally yes, I write some scary side effects in there to hopefully decrease the chances of audit. For example, if I'm giving prolia, I state something like "close monitoring for potential irreversible osteonecrosis of jaw." I have yet to be audited
I could be wrong but I’m pretty sure that would fail an audit as you need to be monitoring with a lab or clinical test (like EKG) not just H&P / physical exam and I don't think there is a lab or clinical test you can monitor for osteonecrosis. You might could argue you're monitoring for hypocalcemia though.

Otherwise I would argue all of your examples EXCEPT Breast on AI meet criteria for “life or bodily function threatening diagnosis” and “therapy requiring intensive monitoring (at least quarterly)” - unless you’re seeing the AI patients every 3 months and monitoring their labs
 
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What are your general benchmarks for 99214 vs 99215 visits? Specific examples would be appreciated.
Do your hospital coders automatically downcode 99215 to 99214?
I don’t work for a hospital but if I did I would probably include very specific language in my note for MDM purposes so the billers can’t play games with you. I have heard in multiple places they will try to downcode you to “prevent problems” (and it just so happens they can pay you less).
 
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