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Coding 99214 vs 99213 for a sick visit

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rgcolumbus:
This year, the pediatric provider that my two children use has started coding all sick visits at 99214.  They used to code them all at 99213.  When I inquired about the change, they told me that they had been under-coding in the past.  I am having a hard time accepting this because the family doctor that I go to codes everything at 99213.  I asked my insurance company to review the records for one of my child's visits and they said that the records met the criteria for a 99214.  I get the feeling that my pediatric provider is making the exam and history complex enough to satisfy the requirements of 99214 even though it may not really be medically necessary.  For instance, one of my children went in to get a cough checked out.  The diagnosis was 'cough' and there was no treatment plan other than to bring her back if it got worse.  She has no medical conditions and is not on any medication.  Yet this was coded as 99214.  Since I have a high deductible health plan, this directly impacts my out of pocket cost.  What should I do?  Am I making too big a deal out of it?  Thanks.

PMRNC:
Right off the bat any provider automatically labeling all sick visits 99214 sends a red flag up to me since each CPT E/M Criteria has to be met within the medical record, which leads me to believe their documentation may not be up to par at all.   I Would contact your carrier and let them know your findings, they will in turn investigate, request records, if they believe they have an issue with that provider on other patient's they will conduct a larger investigation with a red flag on the provider and possible audit. When you said the provider started coding ALL sick visits as 99214, was that something you seen in writing or was told by the provider? That is something you must let the carrier know.   Not only does reporting this help you, but it saves the insurance company and possibly other patient's the added expenses and ultimately this type of potential fraud is part of the big picture on the rising healthcare costs and premiums.  Oh and you can do this under the radar, the carrier will not list it as a complaint, but rather internally investigate it for you.

rgcolumbus:
Thanks Linda.  The provider did not tell me that they are coding all sick visits as 99214, I made this analysis myself by looking at past claims.  In 2011, my children had a total of 7 sick visits.  Six were coded 99213 and one was 99214.  In 2012, my children have had 11 sick visits so far.  Nine have been coded 99214, one was 99213 and one was 99215.  The 99215 is what really caught my attention and got me looking into this.  When I asked the provider about it, they did an audit and said the 99215 was an error and should be 99214.  They also said one of the 99214's should have been 99213.  When I asked why the coding had changed from mostly 99213 in 2011 to mostly 99214 in 2012, they told me that five of the 99213 visits in 2011 had been under-coded.

I tried to get some help from my carrier (Anthem) on this and they have been less than helpful.  They are only interested in looking at one claim at a time, not the overall situation.  So I picked one of the 99214 visits that seemed especially simple and asked them to review it.  It took a total of three months for Anthem to get the records into their system and sent to the review department.  I faxed them twice and then finally mailed them.  I know the provider faxed them a couple times as well.  Anyway, Anthem came back and said that the provider had met the criteria for billing 99214.  They said they do not challenge the provider as long as the records support the billing code.  They said if I disagree with the level of service provided, that is my issue to take up with the provider.  From what I have read online, the provider can pretty easily give a detailed exam and get a detailed history and bill that as 99214, even if there is no medical decision making (since only 2 of the 3 criteria are needed).  I think that is what may be happening here.  Not sure what to do next since we really do like the doctor himself.

PMRNC:
That irks me when we go to an insurance company and hand them a case of fraud and abuse on a silver platter and they ignore it.   Since you do like the provider why don't you try to confront him with all the information directly, NOT biller, but the provider himself? There is always the possibility he isn't aware of what the billing dept/person is doing.

rgcolumbus:
I am told the doctor is aware, but I have not sat down with him personally to discuss.  I'm setting up a meeting with the coder to discuss in person.  I'll let you know if we can come to some agreement.  Is there a place I can find recent national data for typical code utilization to support my argument?  i.e. is 99213 used 70% of the time and 99214 used 30% of the time?

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