CPT Code Medicare Payment*
99204 (Level 4 office visit, new patient) $166.16
99205 (Level 5 office visit, new patient) $209.23
99214 (Level 4 office visit, established patient) $108.74
99215 (Level 5 office visit, established patient) $146.43
When documented and coded appropriately, high-level evaluation and management (E/M) codes translate into greater reimbursement than their lower-level counterparts. However, these codes can also be a source of financial frustration when payers refuse to pay them—a trend that seems to be emerging as physicians use electronic health records (EHRs), says Mike Strong, MBA, CPC, bill review technical specialist at SFM, a workers’ compensation insurer.
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“The templates make it easier to get higher levels when the medical necessity might not be there,” says Strong, who provides E/M education to physicians. Physicians end up foregoing SOAP (subjective, objective, assessment, and plan) documentation methods in favor of simply answering questions prompted by the template that may be completely unrelated to the patient’s presenting problem, he adds.
Strong cites the example of an established patient with asymptomatic diabetes who presents for a blood sugar recheck and prescription refill. A general diabetes template in the EHR may prompt a physician to complete a full review of systems and an eight-organ system exam when medical necessity simply doesn’t justify these services, says Strong.
If physicians create their own templates, they shouldn’t assume that specific diagnoses automatically justify a certain level of E/M service, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC, an organization representing professional coders, billers, auditors, compliance professionals, documentation specialists and practice managers.
For example, some physicians believe that every new patient with abdominal pain justifies reporting CPT code 99204, so they develop an abdominal pain template that supports a level four E/M code. Physicians shouldn’t be prompted to document a level of service, says Jimenez. Instead, they should document elements that support medical necessity, she adds.
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Beware of templates that pre-populate information from previous visits or require physicians to check “all others negative” when completing the review of systems, says Strong. This can lead to artificially high levels of E/M services because the EHR simply counts the information regardless of whether the physician performs the work, he adds.