It’s not all 99203 and 99212 for new and established patients
WE HAVE ALL BEEN THERE — so busy we just do what we can to get by, often using rote processes we think are surefire. However, without realizing it, we can be putting ourselves and our practices at risk.
Improper evaluation and management (E/M) coding not only increases the risk of penalty for incorrect coding but can also mean a significant amount of our money is left on the table. Improperly up- or down-coding may violate federal rules, violate state board rules and breach specific payer rules. These are a few of the many reasons proper E/M coding is so critical to your practice.
It may seem easier to just spin the wheel or estimate which code is appropriate, but the art and skill of E/M coding goes a bit further than this. Gaining a deeper understanding of what each level of E/M represents will help significantly in selecting the most appropriate code for the service performed.
Where to start
The most common code sets seen in the chiropractic office are 99201-99205 for new patients and 99211-99215 for established patients. A new patient is either brand-new to your practice or a patient whose last visit was more than three years prior. Everyone else is considered an established patient. It doesn’t matter if that patient has had a new accident or is covered under a new payer.
The determination is based on the date your office last saw the patient. If you have multiple provider types in the office, for example, MDs or DOs, the new-patient rule applies by provider type — so simply seeing a different chiropractor in the office doesn’t constitute being a new patient.
New vs. established codes
The codes are very specific. The fourth number in the code indicates whether this is a new or established patient visit. The last number demonstrates the level of work and information obtained during the history, examination and clinical decision-making as set forth in E/M documentation guidelines. The American Chiropractic Association (ACA) recommends that all physicians use the E/M documentation requirements developed by the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS).
The code selected for a new patient must meet all three component descriptions in the coding algorithm for the service being reported. The key components of history, examination and clinical decision-making are each measured to determine the final code.
For example, history documentation reflects “Detailed” (99203); your examination reflects “Comprehensive” (99204) and your clinical decision-making reflects “Low” (99203). Using this example, the lowest-level code is selected for the new patient since all three must meet or exceed. When selecting the appropriate code for an established patient, only two of the three areas must meet or exceed.
Don’t I do this at every visit?
Kind of. It is a common misconception that E/M services are indeed provided at each visit. However, the Chiropractic Manipulative Treatment (CMT) codes include elements of the E/M service. Therefore, it may not be appropriate to bill for E/M services day-to-day that are not separately identifiable. These bulleted points outline the components of Pre/Intra/Post service work of the CMT.
Pre-Service work may include a review of:
- the patient’s records
- the diagnostic tests
- communication with other providers
- the actual preparations for care
Intra-service work may include:
- discussion about the service with the patient
- a pertinent evaluation and assessment of the patient
- the procedure performed
Post-service work includes:
- an evaluation and discussion with the patient about the effect of treatment
- arrangement of additional services or referral to another provider
- discussion of the case with other providers
- review of literature about the patient’s condition
- documentation of the service
Because the CMT is the primary service being executed in routine visits, it is also the primary code billed. There may be times when additional E/M services are performed that are separate and distinct from the routine E/M of a CMT service. For example, when separate E/M and CMT services are provided on the same day, it may be appropriate for both to be billed. A new patient E/M with an adjustment on the same day, a periodic re-evaluation during care, or a new condition are examples of when this may occur. In these instances, it is necessary to append the -25 modifier and to verify each payer’s policy on coverage and any additional requirements for these services.
What about time well spent?
There may be some encounters where the three key components of the exam are not evident. For example, in the case of an established patient who presents to the office to discuss the results of blood work, an MRI or other diagnostic study, there is no need to take a history or perform a physical examination.
The Current Procedural Terminology (CPT) manual states, “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services.”
This means that time alone can be used to select a level of care if most of the encounter involves counseling or coordination of care, regardless of the extent of the history, exam or medical decision-making.
For E/M services, counseling may include a discussion of test results, diagnostic or treatment recommendations, prognosis, risks and benefits of management options, instructions, education, and compliance or risk-factor reduction. Often, there isn’t separate coverage under certain policies, so even if you’ve coded it correctly, be sure to check before you bill.
What about report findings?
Many doctors want to charge for the time spent doing the clinical report of findings. After all, you spent the time with the patient; shouldn’t you get paid? Unfortunately, there is no appropriate code for reviewing the results of the exam or x-rays with the patient, as this is a component of the initial exam. In many chiropractic offices, we split what would be one visit over two days as we process/review the film, complete our medical decision-making and complete our documentation required to support the E/M service. Because there is no appropriate code for a separate review, it is not possible to bill for both visits.
As we perform documentation and billing audits for our clients, it is surprising how much money we find lying on the table because of inappropriate E/M coding. Don’t slip into the rut of just selecting the code you have always used or spinning the wheel of guessing; instead, arm yourself with the knowledge and tools to ensure that the most appropriate code is used for the services you are performing. Not only will this positively improve your adherence to compliance regulations, it will likely impact your pocketbook with increased revenue.
KATHY MILLS CHANG,MCS-P, CCPC, CCCA, has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices since 1983. She leads a team of 30 at KMC University and is known as one of our profession’s foremost experts on Medicare, documentation and CA development.
YVETTE NOEL, CPCO, is a senior membership advisor and conference speaker with KMC University. She has served the chiropractic community for 13 years and has worked in the medical field since 1988. Kathy, Yvette or any of their team members can be reached at 855-832-6562 or info@KMCUniversity.com.