Coding > Coding

Coding 99214 vs 99213 for a sick visit

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dekenn:
My goodness! Let's convict him now! Why is it assumed this is a case of fraud and abuse? The patient states that she complained to the insurance company, they reviewed it, and determined that 99214 was appropriately billed.......

DMK:
I hesitated to jump in, but if the kid was sick, and you're happy with the doctor's care, and the ins. co. reviewed and it was appropriately billed, pay your bill!  We're talking CARE, not $$$.

rgcolumbus:
The bill has long been paid.  The issue I have is not because of a single visit, it is the overall pattern. 10 out of 11 visits so far this year have been billed at 99214.  Is that normal?  My kids don't have chronic conditions or complex medical needs.  These are visits for seasonal colds or bronchitis.  I need some convincing that 99214 services are really justified this often.  The other aspect is that every time I see my family doctor, they bill 99213.   And, the pediatric provider used to bill 99213.  So all this together makes me feel like something is wrong.  The $$$ add up when your kids see the doctor 10-15 times per year.

DMK:
I'm not sure if you have access to the CPT book so maybe this will help define each situation:

99213 Expanded problem focused history
          Expanded problem focused examination
          Medical decision making of LOW complexity
          (Condition is of low to moderate severity, although the code is NOT time based, this would typically be  a 15 minute appointment)

99214 Detailed history
          Detailed examination
          Medical decision making of MODERATE complexity
          (Condition is of moderate to high severity, although the code is NOT time based, this would typically be a 25 minute appointment)

99215 Comprehensive history
          Comprehensive examination
          Medical decision making of HIGH complexity
          ( Condition is of moderate to high severity, although the code is NOT time based, this would typically be a 40 minute appointment)

A cold, 99213, bronchitis 99214, broken arm from an accident 99215. (Examples)  When tests are ordered it's higher complexity.

I'm not sure of your background or medical experience, so I hope these definitions will help to reconcile the billed codes with the services you received.

Also, undercoding is just as bad as overcoding.  Medicare will slap you hard for not billing appropriately.

rgcolumbus:
Thanks.  I do not have a medical background, but I have read quite a bit about these particular codes during this process.  The definitions and guidelines are pretty easy to find online.

For the example that I sent to the insurance company for review, the chief complaint was: 'cough, congestion'.  The Assessment was 'cough'.  There was no medication prescribed.  The provider gave me the medical records.  For this visit, they classified the history as detailed, the exam as comprehensive, and the decision making as low.  Since 2 of the 3 criteria are needed, this met the 99214 level.  Since the records back up the detailed history and the comprehensive exam, the insurance company is OK with it.

So, it makes me question if a detailed history/comprehensive examination is a reasonable and necessary for these symptoms.

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