Times are tough for primary care physicians—so tough that American Academy of Family Physicians’ President Jim King, MD, recently called for health care reform to ensure that coverage is affordable and that “physicians can continue to care for [patients] without fear of bankruptcy.”1 Yet in virtually every family practice, opportunities to maximize reimbursements are missed. Undercoding, omitting modifiers, and submitting claims without the documentation needed to support them are everyday events.
The lost revenue is no small change. At the current Medicare reimbursement rate of $96.01 for a 99214 visit and $63.73 for a 99213 visit, a physician who undercodes just one level 4 visit per day could lose as much as $8,393 over the course of a year.2
Some family physicians undercode simply because they underestimate the value of the services they provide. Others deliberately take a conservative approach in hopes of avoiding a government audit—a misguided tactic that some coders believe is as likely as habitual overcoding to arouse suspicion.3 For still other physicians, the time it takes to document a level 4 visit is not worth the trouble. Brushing up on the requirements for higher-level visits (TABLES 1 AND 2)4 and using encounter templates to guide you through a review of systems, symptoms, and severity can help lighten the documentation load.
To provide additional help, we’ve developed 10 coding and billing tips based on our experiences in family practice. Each of these can help you to maximize reimbursement.
TABLE 1
Established patient visits: CPT codes and documentation requirements
| E/M CODE | |||||
|---|---|---|---|---|---|
| 99211 | 99212 | 99213 | 99214 | 99215 | |
| History | |||||
| Chief complaint | Required | Required | Required | Required | Required |
| History of present illness | NR | 1-3 elements | 1-3 elements | ≥4 elements or ≥3 chronic diseases | ≥4 elements or ≥3 chronic diseases |
| Review of systems | NR | NR | 1 system | 2-9 systems | ≥10 systems |
| Past history/family history/social history | NR | NR | NR | 1 element | ≥2 elements |
| Examination | NR | 1 system (1-5 elements) | 2 brief systems (6-11 elements) | 1 detailed system + 1 brief system (≥12 elements) | 8 systems or 1 complete single system (comprehensive) |
| Medical decision making | |||||
| Risk | NR | Minimal | Low | Moderate | High |
| Diagnosis or treatment options | Minimal | Minimal | Low | Moderate | High |
| Data | NR | Minimal | Low/Moderate | Moderate | High |
| Time* | 5 minutes | 10 minutes | 15 minutes | 25 minutes | 40 minutes |
| CPT, current procedural terminology; E/M, evaluation and management; HPI, history of present illness; NR, not required. | |||||
| *At least one half of total face-to-face time must involve counseling or coordination of care. | |||||
| Adapted from: American Medical Association.4 | |||||
TABLE 2
New patient visits: CPT codes and documentation requirements
| E/M CODE | |||||
|---|---|---|---|---|---|
| 99201 | 99202 | 99203 | 99204 | 99205 | |
| History | |||||
| Chief complaint | Required | Required | Required | Required | Required |
| History of present illness | 1-3 elements | 1-3 elements | ≥4 elements or ≥3 chronic diseases | ≥4 elements or ≥3 chronic diseases | ≥4 elements or ≥3 chronic diseases |
| Review of systems | NR | 1 system | 2 systems | ≥10 systems | ≥10 systems |
| Past history/family history/social history | NR | NR | 1 element | ≥3 elements | ≥3 elements |
| Examination | 1 system (1-5 elements) | 2 brief systems (6-11 elements) | 1 detailed system + 1 brief system (≥12 elements) | 8 systems or 1 complete single system (comprehensive) | 8 systems or 1 complete single system (comprehensive) |
| Medical decision making | |||||
| Risk | Minimal | Minimal | Low | Moderate | High |
| Diagnosis or treatment options | Minimal | Minimal | Low | Moderate | High |
| Data | Minimal | Minimal | Low | Moderate | High |
| Time* | 10 minutes | 20 minutes | 30 minutes | 45 minutes | 60 minutes |
| CPT, current procedural terminology; E/M, evaluation and management; HPI, history of present illness; NR, not required. | |||||
| *At least one half of total face-to-face time must involve counseling or coordination of care. | |||||
| Adapted from: American Medical Association.4 | |||||
1. Document and bill more 99214s
Centers for Medicare & Medicaid Services (CMS) data show that in 2006, family physicians billed 55.2% of their established outpatient visits as level 3s (99213) and 31.6% as level 4s (99214).2 Evidence suggests that the percentage of 99214s could legitimately be higher. A study comparing family physicians’ choice of codes with those selected by expert coders revealed that the physicians undercoded one third of their established patient visits. In most cases, visits that warranted 99214 codes were instead coded as 99213s.5
To bill for a level 4 established patient visit, CPT (Current Procedural Terminology) guidelines require you to fulfill 2 out of 3 of the following components:
- a detailed history
- a detailed physical examination
- medical decision making of moderate complexity.4
When the history and medical decision making indicate a higher level of complexity, you can bill for a 99214 visit without having to count or document individual body systems or detailed exam elements. A new diagnosis with a prescription, an order for laboratory tests or X-rays, or a request for a specialty consult are all examples of moderately complex decision making. When it is necessary to show that you performed a comprehensive system review to justify a 99214 claim, history forms, filled out in the waiting room and subsequently reviewed with the patient, can be a valuable time-saver.
2. Avoid the 99203/99204 “complexity” pitfall
In 2006, CMS data showed that family physicians billed 43.9% of new patient visits as level 3s (99203) and just 28.5% as level 4s (99204).2 In many cases, opportunities to bill for 99204s are missed.
Unlike a level 4 visit for an established patient, a 99204 code requires all 3 components—a detailed history, detailed physical examination, and moderately complex decision making (TABLE 2).4 Thorough data collection is crucial to justify the higher level code, which is appropriate whenever a new patient presents with a complex medical history warranting a new diagnosis, new medication, and tests or a specialty evaluation.