Document Your Level IV Visits With Confidence

Family physicians may have concerns about the documentation of Level IV visits. Some physicians recently reported receiving a letter from a health plan (e.g., Blue Cross, Humana, Guardian) or Medicare warning that their use of high-level codes (Levels IV or V) was greater than other physicians in their specialty.  Some health plans request  medical records while others alert physicians about possible problems with their data and ask to review the physicians'  billing practices to ensure they are in accordance with the Current Procedural Terminology (CPT) Evaluation and Management (E/M) coding requirements and the Center for Medicare and Medicaid Services (CMS) 1995 or 1997 documentation guidelines. 

Physicians believe they could be coding more patient visits at Level IV, but are unsure what documentation is required and fearful of being audited. The result is physicians undercode to be safe. This is unfortunate because proper coding could add more revenue to the practice.  If a physician has 20 patient visits and at least two of those visits are coded at Level IV instead of Level III, the result is an additional $100 per day or $500 per week. This means additional revenue of up to $20,000 annually for a practice. It is important for family physicians to code with confidence and understanding of what is sufficient documentation to support the level of care they are providing. 

Any E/M service has three key components: history, exam and medical decision making.  For an established patient visit, two of the three components must meet specific criteria when performing the service. For a new patient visit, all three of the key components must meet specific criteria. A Level IV established patient visit requires a detailed history, a detailed physical exam and medical decision making at a moderate complexity level. 

A summary of the criteria for a 99214 visit is below. 

Detailed History 

The history component of the visit is fairly straightforward.  Begin the note with a chief complaint (i.e., the reason the patient came to see you).  Then add an extended history of present illness (HPI) that includes four or more descriptive elements about the chief complaint from the following choices: location, quality, severity, duration, timing, context, modifying factor or associated signs and symptoms.  While only four elements are required, you can certainly add more elements if needed to fully describe the chief complaint. 

According to the 1997 Documentation Guidelines (see 1995 vs. 1997 side bar), you can also meet the HPI requirements by documenting the status of at least three chronic conditions.  The key phrase to remember here is "status of."  It is insufficient, for example, to document that a patient has hypertension, diabetes and asthma.  Instead, you might document as follows: "Patient has hypertension controlled with diet and exercise, diabetes controlled with insulinand asthma requiring an inhaler twice daily."

An extended review of systems (ROS) is required for this visit and can be fulfilled by noting two to nine systems associated in some way with the chief complaint.  CPT recognizes 14 possible systems as part of the ROS. 

Finally, a pertinent past, family and social history must be noted.  This involves documenting at least one specific item from any of the three history areas.  A commonly used notation is "non-smoker."  That phrase helps fulfill your history requirement.

Here is how you would determine what your level of history would be: 

In many cases, the criteria for a detailed history may be the easiest to fulfill.  Once the level of history is documented, you only need one of the next two components to meet the necessary criteria for a Level IV established patient visit. 

Detailed Exam

Documenting the exam may be a little more challenging if you do not have the time or need to perform a detailed exam in a short visit or straightforward complaint.  To meet the visit criteria according to the 1995 guidelines, five to seven body areas or other symptomatic-related organ systems must be examined and documented. The body areas include the head, neck, chest, abdomen, genitalia, back and each extremity.  The organ systems include constitutional (e.g., vital signs), eyes, ear, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric and hematologic (lymphatic and immunologic systems are included with this one). 

Here is how you determine your level of physical exam:

A notation indicating "negative" or "normal" is sufficient to document normal findings of a physical exam. 

Moderate Complexity Medical Decision Making

This component can be the deciding factor as to whether your visits achieve Level IV status.  It is divided into three sections - Diagnosis, Data and Risk - that are used to determine the complexity of the patient encounter.  To qualify for any one of the specific levels of medical decision making (straightforward, low, moderate or high) only two of the three areas are required.  The diagnosis and data sections can be simplified with a point-scoring system as illustrated below:

Number of Diagnoses or Treatment Options

The Diagnosis Section deals with the number of possible diagnoses or the management options that must be considered.  Three points are needed to meet the 99214 criteria.  If your patient has a new, previously undiagnosed problem, you have met the criteria for this component of medical decision making. 

If you are dealing with an established, previously-diagnosed problem, decision making will be less complex, and the patient will have to have more than one problem to meet the Level IV criteria.  An established problem that has worsened earns two points.  An established problem that is stable earns only one point.  In this case, you could add points for each of three stable problems or have one stable and one worsening problem and score three points for the diagnosis section.

The Data Section deals with the amount and complexity of data to be ordered or reviewed.  Like the diagnosis section, the data section requires three points to qualify for a Level IV code.  The easiest way to achieve three points is to order an X-Ray, ECG and blood work.  You can earn two points for both review and summarization of old records and discussion of the case with another health care provider.  If you combine that with ordering any testing, you can earn three points.

The Risk Section is based on the overall risk associated with the presenting problems, diagnostic procedures and management options.  The highest level of risk in any one of these three categories determines the overall risk. 

Click here to view the complete Table of Risk.  A moderate risk is required for a Level IV code. 

For the presenting problem to be of moderate risk, your patient needs to have one chronic illness with mild exacerbation,  two or more stable chronic illnesses, an undiagnosed new problem with uncertain prognosis, an acute illness with system symptoms or an acute complicated injury.  The other two categories of risk usually follow the presenting problem. 

Using the point system for the Diagnosis and Data Sections and the Table of Risk, your Medical Decision Making Summary should look like this:

Time-Based Billing

Often a quick acute illness visit turns into a much longer visit due to patient needs.  If you spend at least 25 minutes with the patient and more than half of that time is spent counseling the patient, you are qualified to code a visit as Level IV irrespective of the history, exam and complexity criteria described above.  Document your visit as appropriate, but remember to document the content of your counseling or care coordination and report the total visit time and counseling time.  For example, you might report that the "total visit time was 25 minutes, more than half of which was spent counseling the patient and coordinating care." 

Code Correctly

Undercoding to stay on the safe side is not financially viable.  You may have incorrectly coded in the past due to lack of knowledge or out of fear.  In the future, be compensated for the complex work that you perform every day by following these simple rules for Level IV visits.

Documentation Guidelines 1995 vs. 1997

The Choice is Yours!

It is up to the individual physician whether he or she chooses to use the 1995 documentation guidelines or the 1997 documentation guidelines  The biggest area of difference in the two sets of guidelines is documenting the physical exam. 

In the 1995 guidelines, the level of exam depends on the number of body areas or organ systems examined and documented.  They do not specify what constitutes an exam of any area or organ system.  They do not indicate how much documentation is necessary to substantiate that the area or system in question has, in fact, been examined. 

The 1997 guidelines define complete exams for 11 organ systems and significantly expand the definition for multisystem exams. 

Either version may be used, but it is not permissible to combine them on any one patient.  For example, you cannot use the 1997 guidelines for history and the 1995 guidelines for exam and medical decision making.   It is permissible, however, to use the 1995 guidelines on one patient and the 1997 on another. 

Mary Jean Sage has extensive experience in the health care field spanning a period of more than 20 years during which time she has managed diverse groups of professionals in delivering patient care.  A founding Principal and Senior Consultant with The Sage Associates, Mary Jean is a nationally-known speaker, consultant and educator. 

DISCLAIMER

The articles provided in Practice Management News are general.  They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship.  Consult your attorney or other professional for advice in your particular situation.

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