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[Carti]

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[reno911]

There are relatively new guidelines that are very well laid out for the E&M codes. If certain criteria are met, then the amount of time doesn't matter.

There is no way anyone here can tell you if the coding/billing is inappropriate without at least seeing a note and what was billed. That's also exactly what an auditor would do.

Depending on the scenario, if I was curious, I'd ask something like "What makes this visit a level 4?" If this is an attending/resident situation, then I think that is a perfectly legitimate question. Residents need to learn to billing and coding and it's not taught nearly enough in residency.

 

[dermie1985]

Dermatology as a specialty had one of the highest increases in Level 4 return coding (99214's) as part of the updated guidelines for billing implemented in 2021. This has to do with the nature of us managing many chronic skin disease that require prescription drugs.

Most providers don't bill on time, unless it's a long visit with not much medical decision making and just a lot of discussion/counseling (e.g. delusions of parasitosis patient who leaves your office with nothing). Most encounters are billed on medical decision making / complexity, which may have no correlation to time spent with the patient.

95% Level 4's seems potentially suspect to me - e.g. a typical skin check will be hard to be anything more than a Level 3 unless there is a separate problem addressed (e.g. acne, eczema, etc.) that requires a prescription medication. But, it's not uncommon for dermatologists to bill Level 4 visits even for short visits.

 

[doctalaughs]

It totally depends on documentation not time.

Usually if you can document that you reviewed X number of labs or went over X number of outside notes or corresponded with another doc then you can bill a 99214.

If that isn’t in the documentation then no you can’t in a normal skin check unless you prescribed something. OTC like sunscreen or nicinamide doesn’t get you to 99214.

I’ve seen some creative ways to bill mostly 99214 on a skin exam though. If you prescribe or refill something for every patient (efudex, Aldara, retin-a etc) then usually you can justify it with the right note template.

 

[Solodyn]

I'm currently working at a dermatology office with one dermatologist where every visit, even 5 minute encounters, is billed as a 99214. Since I started working here, I've seen maybe one visit billed as 99213.

From my experience at other offices, this appears to toe the line for unethical behavior, but I wanted some opinions from attendings on whether this would be constituted as upcoding. Are dermatology visits commonly billed as 99214 regardless of time spent/complexity? Should I report this to my medicare compliance officer?

The new guideline for derm visits is now based more on medical complexity rather than 1995/1997 guideline. This is released around 2020. Based on the old guidelines, it is very hard to get everything you need for a level 4 visit. However, based on the new guideline, if you have one new chronic condition or 2 stable chronic conditions, etc you can bill for level 4 very easily. I would recommend that you research the new guideline prior to making an accusation about Medicare fraud or unethical behavior. The proper next step would be to discuss with the internal compliance officer within the practice. More than likely, they will educate you on why what they are doing is legal, which is more than likely to be the case. If your employer has a compliance plan, then that is your next step course of action.

 

[DoctwoB]

Not a derm but also a specialist. I’m probably 85% 4s; 10% 5, 5% 3.

It is a rare visit that I’m not dealing with one new problem or two chronic problems and I don’t prescribe, refill, or even discuss prescribing a medication.

 

[forchinet121]

Not a derm but also a specialist. I’m probably 85% 4s; 10% 5, 5% 3.

It is a rare visit that I’m not dealing with one new problem or two chronic problems and I don’t prescribe, refill, or even discuss prescribing a medication.

How you getting 4s without prescribing a med? It has to be 2 conditions plus a med right?

 

[sloh]

How you getting 4s without prescribing a med? It has to be 2 conditions plus a med right?

Discussed a med

 

[forchinet121]

Discussed a med

He says in that quote he doesn’t discuss lol

 

[sloh]

He says in that quote he doesn’t discuss lol

I think he worded it weird haha. I think he means he always DOES prescribe, refill, or discuss a med.

And that last one has plenty of room to fudge. Not saying he does but it’s easy to fudge lol.

 

[doctalaughs]

One thing that I’d like to hear from an expert derm coder is what really can count as 1 “undiagnosed new problem” or 2 “stable chronic illnesses”.

Are all “neoplasm skin” where you do a biopsy countable as an “undiagnosed new problem” (I’ve heard some claim that - but I’m a bit doubtful as usually with a biopsy you can’t also do an e/m for that no matter the wording/discussion).

Is xerosis or sun damaged skin “stable chronic illness” when discussing sunscreen/emollient etc? These are codable in almost all visits - and that’s how I think some can justify 99214 (when you throw in a med refill) on 95% of there visits which is *probably* going to pass muster on an audit even if I’m more conservative.

 

[sloh]

One thing that I’d like to hear from an expert derm coder is what really can count as 1 “undiagnosed new problem” or 2 “stable chronic illnesses”.

Are all “neoplasm skin” where you do a biopsy countable as an “undiagnosed new problem” (I’ve heard some claim that - but I’m a bit doubtful as usually with a biopsy you can’t also do an e/m for that no matter the wording/discussion).

Is xerosis or sun damaged skin “stable chronic illness” when discussing sunscreen/emollient etc? These are codable in almost all visits - and that’s how I think some can justify 99214 (when you throw in a med refill) on 95% of there visits which is *probably* going to pass muster on an audit even if I’m more conservative.

You should go to the psychiatry forums haha. There's so much gray wrt what is a stable or unstable chronic illness and plenty of room for interpretation. If the documentation supports it, it will likely pass muster on an audit.

 

[ObsequiousAplomb]

Stable for coding purposes means at treatment goal. So unless it's a fully successful treatment it's more severe than "stable."

Sloh is right. You should check out what we say about it in psychiatry. Technically if someone has any symptoms of depression at all then it's not considered stable yet. I imagine it's similar for xerosis or other rather benign conditions y'all treat. Until their skin is back to normal it's probably a progressive, chronic problem (but not life threatening or severe).

So yeah, there's a good argument for:
S: dry skin for 3 years. Has tried OTC x, y, and z. Steadily getting worse.
O: dry skin
A: xerosis
P: discussed Rx

Potentially making the muster for 99214. If it's dry skin plus any other problem, then it absolutely does.

 

[forchinet121]

I mean he should probably just ask a coder in his field rather than relying on what the psych forum members think

 

[sloh]

I mean he should probably just ask a coder in his field rather than relying on what the psych forum members think

With the caveat that coders are very inconsistent in their recommendations—even within the same field. That’s been my experience with my specialty (PM&R)

Also check out this EM thread:

2023 CPT Guideline Changes

Pretty sure that my point still stands. MDM complexity is defined by 3 categories, of which 2/3 are required for 99285 billing. 1. Testing, document review, or independent historian 2. Independent interpretation of testing performed by another healthcare professional— which is basically...

forums.studentdoctor.net

I sure hope our billers and coders have enough brain cells between them to figure this out. Given the kind of charts I get sent back for completion, which already has the documented information they're asking for, I'm not so sure.

The problem we have is our biller/coder Optum is just terrible and our billing was even worse in 2023, and we've had to fight tooth and nail for them to resubmit midcoded charts. Optum is so bad

our billing/coder Optum likes to code several lac repairs as low risk and not moderate risk, despite ACEP clearly outlining that the vast majority (or all) lac repairs should be moderate

lots of downcoding on the complexity of problems addressed. For instance, one of our docs had a F with RLQ pain and vomiting and report of being pregnant. First on ddx was ectopic pregnancy. That suggests highest complexity of problems - yet Optums said it was "moderate complexity."

BTW our biller/coder is Optum and they are simply terrible. what a terrible experience.

Based on how long it takes us to get data from the coding/billing folks, we won't know we're f*cked until late Q2...

We are kind of seeing the same thing. More 3's going to 4's. However our coder/biller is still giving us way too many 2's, of which there should be just about none. If you make a chart in the ED it's probably < 1% chance it's a 2. Unless the pt is there to "get a new bandaid" or "I'm hungry" or something. We are working with them.

I’ll always try to buff up the 3 data points (extra history from EMS or family, old records, considered ordering xyz). I’ll generally try and interpret some sort of imaging, even if it was not done same day. Risk of complications is the grey area. Social determinants or Rx management = easy level 4.

So guys and gals....is it possible to get 99284 on a 1 yo with a routine, simple URI?

Here's how you get it, I believe:

- COPA (Complexity of Problems Addressed) will always be Low (not sure how you get 'Moderate' from a simple URI with a runny nose and cough)

- Data can be Moderate. Review a prior, non-ER note like from PCP. Order a respiratory viral swab. Get history from Mom or Dad.

- Risk can be Moderate. Write Rx for tylenol.

Boom! Because you pick any two of the three highest levels, you get a Moderate chart which is 99284.

Do I have this right?

Ok, so for the sake of argument, why shouldn't this be a 5? I considered the possibility of an atypical or early presentation of pneumonia, bacteremia, deep space neck infection or meningitis, all highly morbid procedures. I consideredperforming labs, blood cultures, a CXR and a viral respiratory panel. I considered an Rx for empiric antibiotics or antipyretics. Hospitalization, for monitoring of progression or development of compliations was considered. This was discussed with the parents.

The fact is, while not always, we often glance and read prior charts and labs when making decisions. Want to know the pt's prior Cr or QT interval? we often look at stuff and just do things out of habit like reconcile pt meds in our head when making decisions and much of this counts towards. And we do these decisions in seconds, not minutes.

I suspect ultimately that insurers will be watching the ratios of all their coded charts carefully. If a ER group had in prior years a ratio like 20% 99283, 40% 99284, and 40% 99285 going back a few years...and now all of a sudden MDs are charting or claiming that it's now 5% 99292, 30% 99284 and 65% 99285, they will call BS and just not give it to you. Patients didn't magically get more sick on Jan 1 2023.

Chest pain gets a "High risk possible diagnoses include ACS" in my chart (assuming I'm getting an EKG and a trop, even if it's a 30 yr old and the trop was ordered in triage).

Abd pain getting imaging gets: High risk possible diagnoses include perforated hollow viscous, appendicitis, blah blah blah that you would see on a CT scan so writing it down shouldn't open up much medmal risk

Did I order a cbc and a chem only? You bet I'm either documenting one thing family said, or checking their med fill history or whatever to get that 2nd column up to 3 points of data and thus at least a lvl 4.

Everyone who isn't getting admitted either gets a Rx or gets documentation regarding why I considered, but did not provide an Rx. That gets you a lvl 4 at least in the Risk column.

It's all a stupid game. The only part I don't have solidly down (because our coders have been mum on it) is whether my "high risk" comments above are actually checking the box for a lvl 5 chart in the COPA column as that's ultimately at their discretion. The other two columns are pretty checkbox in nature.

Time to play the new game.

ROS requiring use of macros and slights of truth was stupid, but almost easier.

Now it’s every chief complaint is initially a risk for deterioration of that organ and life threatening, but upon further evaluation no serious condition identified.

Everyone’s prior records get briefly reviewed and quickly summarized.

Of course I talked to an alternative historian! Their family member/friend/significant other/friend with benefits also speculates that the patient’s belly pain is due to the jalapeños as they munch down the remaining French fries from their fast food themselves.

Everyone tries to come for physicians’ money instead of appropriately paying them for their hard work and expertise. We’ll beat them at this new game. Yet we’ll spend a little more time documenting temporarily until we get all the new macros created furthering demoralization. Thank goodness for wellness seminars…

 

[doctalaughs]

With the caveat that coders are very inconsistent in their recommendations—even within the same field. That’s been my experience with my specialty (PM&R)

Also check out this EM thread:

2023 CPT Guideline Changes

Pretty sure that my point still stands. MDM complexity is defined by 3 categories, of which 2/3 are required for 99285 billing. 1. Testing, document review, or independent historian 2. Independent interpretation of testing performed by another healthcare professional— which is basically...

forums.studentdoctor.net

Oh we’ve gone though a lot of coders and even used outside “expert” derm coders.

They know a lot less than you think and you are right that opinions differ.

 

[reno911]

Oh we’ve gone though a lot of coders and even used outside “expert” derm coders.

They know a lot less than you think and you are right that opinions differ.

Exactly this. They are a good resource, but far from infallible. Trust but verify.

 

[ObsequiousAplomb]

I mean he should probably just ask a coder in his field rather than relying on what the psych forum members think

Good thing I didn't tell him to rely on it then, right?

 

[droliver]

There are very few established patient visits in Derm that would meet a level 4 visit, certainly not one lasting 5 mins. It’s dishonest on it’s face

 

[Slack3r]

There are very few established patient visits in Derm that would meet a level 4 visit, certainly not one lasting 5 mins. It’s dishonest on it’s face

Are you sure you know how to use the new E/M coding guidelines? A patient with an acne flare (chronic illness with exacerbation = moderate) that receives a prescription for doxy or tretinoin (prescription drug management = moderate) would meet the criteria for a level 4 visit. That’s a <5 min visit that is VERY common in derm.

There’s actually not a whole lot of established patient visits aside from skin checks that don’t meet the criteria for level 4 visits.

 

[doctalaughs]

Are you sure you know how to use the new E/M coding guidelines? A patient with an acne flare (chronic illness with exacerbation = moderate) that receives a prescription for doxy or tretinoin (prescription drug management = moderate) would meet the criteria for a level 4 visit. That’s a <5 min visit that is VERY common in derm.

There’s actually not a whole lot of established patient visits aside from skin checks that don’t meet the criteria for level 4 visits.

I checked and I’m about 50/50 for level 3 and 4 visits (including both new and established) and I consider myself pretty conservative in coding. Essentially all rash, acne visits and skin checks where you needed to prescribe something (aldara/efudex) are an easy level 4. Plus any immunosuppressive monitoring that will need labs.

Definitely the poster above saying “very few” derm visits can meet level 4 coding is not understanding the guidelines. I do know some dermatologists that like above are like 90+ % level 4, but I don’t see how they really justify that.

 

[OraclePL]

One thing that I’d like to hear from an expert derm coder is what really can count as 1 “undiagnosed new problem” or 2 “stable chronic illnesses”.

Are all “neoplasm skin” where you do a biopsy countable as an “undiagnosed new problem” (I’ve heard some claim that - but I’m a bit doubtful as usually with a biopsy you can’t also do an e/m for that no matter the wording/discussion).

Is xerosis or sun damaged skin “stable chronic illness” when discussing sunscreen/emollient etc? These are codable in almost all visits - and that’s how I think some can justify 99214 (when you throw in a med refill) on 95% of there visits which is *probably* going to pass muster on an audit even if I’m more conservative.

My two cents:

NUB - no. Doesn’t count towards coding if you’re biopsying.

Xerosis - minor.

Actinic damage - this one is harder. I think it depends on your visit and documentation. If it’s just a throw in, probably doesn’t meet criteria. But if patient has severe photodamage and you actively addressed it w sunscreen, nico, or field therapy - then I think this is a chronic condition.

But I think your question is a very good one. I’ve also struggled with exact delineation between chronic and minor. I haven’t seen any clear resources or guidelines here.

 

[username456789]

There are very few established patient visits in Derm that would meet a level 4 visit, certainly not one lasting 5 mins. It’s dishonest on it’s face

This is entirely untrue, as outlined above. 99214 is actually much more common these days with the newer coding guidelines.

 

[reno911]

There are very few established patient visits in Derm that would meet a level 4 visit, certainly not one lasting 5 mins. It’s dishonest on it’s face

This is completely untrue since they revised the coding guidelines.

Edit: Looks like a few others beat me to it.

 

[mike-sheree]

Y’all are in the high cotton. In path we are SPECIFICALLY told how EACH case MUST be coded for all intents and purposes.You cannot make a gallbladder with “itis” anything other than that. Has ZERO to do with time or effort, etc.

 

[asmallchild]

Y’all are in the high cotton. In path we are SPECIFICALLY told how EACH case MUST be coded for all intents and purposes.You cannot make a gallbladder with “itis” anything other than that. Has ZERO to do with time or effort, etc.

The new coding guidelines for E/M are significantly different from what we previously had

I don't do much general derm these days but at our last internal coding seminar, our company's billers are indicating that a prescription essentially means moderate complexity which triggers an established level 4

Agreed, has nothing to do with time or effort

 

[username456789]

The new coding guidelines for E/M are significantly different from what we previously had

I don't do much general derm these days but at our last internal coding seminar, our company's billers are indicating that a prescription essentially means moderate complexity which triggers an established level 4

Agreed, has nothing to do with time or effort

I mean, that’s a huge over simplification, but yes Level 4 visits are much easier these days.

Prescription only gets you to moderate risk, 1 of 3 criteria. If it is a chronic problem (not presently at goal) that can be expected to last 1 year or more, that is considered moderate complexity and you now have a 992X4.

Allergic contact dermatitis from gardening over the weekend —> prednisone rx —> 992X3

Seb derm —> ketoconaxole rx —> 992X4

Right or wrong, that’s how it is now.

It gets a little more confounded when you have 2+ chronic stable problems.