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Here's why high-level E/M codes mean more money


When documented and coded appropriately, high-level E/M codes translate into greater reimbursement than their lower-level counterparts

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
*national average

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.

Next: Copy-and-paste functionality cause problems


Copy-and-paste functionality can also cause problems because physicians don’t take the time to validate whether information is relevant to the current visit and override the suggested code when it doesn’t seem accurate given the patient’s presenting problem, says Mueller. “It shouldn’t be 10 years’ worth of information that doesn’t impact anything for today’s visit. If it is old information that has nothing to do with the current visit, then it’s just past history,” she adds.

Reserve CPT codes 99215 and 99205 for patients at significant risk for loss of life or bodily function, says Kim Huey, MJ, CHC, CPC, an independent coding and reimbursement consultant. This could include, for example, patients with symptoms of an impending heart attack or a severe exacerbation that requires additional workup or an immediate referral to a specialist or the hospital, she adds.


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Also, think about E/M levels for the same patient over time. Payers generally want to see a slow progression downward in the levels, says Strong. For example, when an established patient presents with an acute exacerbation of COPD, a physician might bill CPT code 99215. However, the payer wouldn’t expect the physician to continue to bill that code for each subsequent visit over the next few months.


Avoid denials for level four and five E/M services

Avoiding denials for level four and five evaluation and management (E/M) services requires an attention to detail when reporting diagnoses.

Physicians should include all of the diagnoses they manage and treat, says Raemarie Jimenez,CPC, CPC-I, manager of new product development at AAPC. “Sometimes people get lazy with submitting all of the conditions that are relevant for a patient for that date of service,” says Jimenez. “This may look to the payer that there’s not enough medical necessity for the level of service provided.”

Be as specific as possible, she adds. For example, reporting CPT code 99215 with unspecified asthma rather than severe persistent asthma with acute exacerbation can lead to a denial.


High-level E/M codes: Ensure compliance to avoid payer scrutiny

Some physicians report that they’ve received letters from payers stating they bill too many level four and five E/M visits as compared with their peers. Should physicians be concerned?

Next: Don’t ignore any payer communications


Don’t ignore any payer communications that point out irregularities in the data, says Raemarie Jimenez, CPC, CPC-I, vice president of membership and certification solutions at AAPC. “The payer is taking the time to say, ‘Listen, you’re an outlier. You need to take a look at what you’re doing to make sure you’re not doing anything wrong.’”

In some cases, higher-level E/M codes are justified because patients truly require more complex medical decision-making or time. Physicians also need to remember that patient behavior has changed, says Jimenez. In particular, patients with high-deductible health plans don’t present as often to their physicians.


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“When they do get to the physician’s office, they want them to take care of a lot of things at that one time,” she says. “Physicians are saying, ‘I need to take care of as much as I can while they’re here because I don’t know if they’ll come back.’” This could result in higher-level E/M codes which, to a payer, might look suspicious. However, as long as documentation justifies the higher-level code, physicians should be in the clear, she adds.

On the other hand, a physician’s E/M levels could be higher than average due to flawed templates that lead to up-coding, EHR-prompted codes that a physician doesn’t validate or numerous other reasons.

Take the time to review the volumes of E/M levels reported. Compare it to specialty-specific Medicare utilization data available at bit.ly/Medicare-B-utilization. Click on the file that says, “CY 2015 Evaluation and Management (E/M) Codes by Specialty.” The AAPC also provides a free E/M utilization benchmark tool (bit.ly/AAPC-EM) to help physicians compare their data to peers in the same specialty.


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