99213 v 99214 CPTs - the bigly Medicare / Insurance rip that Congress must address

Without getting too complex - doctors 'code' visits so that they get paid on services they've provided. Think - your first ever visit to a doctor would cost more because they're going to spend more time with you getting history, etc. so they're going to (generically) get paid more than a 2nd visit in which a 'follow-up' is shorter and less complex.

For instance: E/M University explains '99213' as "This level of care is located “in the middle’ of the coding spectrum for office visits with established patients. The 99213 is the second most popular choice for internists who selected this level of care for 41.78% of these encounters in 2014. Usually the presenting problems are of low to moderate severity. The reimbursement for this level of care is $73.40 and is worth 0.97 work RVUs." Adding:

The documentation for this encounter requires TWO out of THREE of the following:

1) Expanded Problem Focused History
2) Expanded Problem Focused Exam
3) Low Complexity Medical Decision-Making

E/M explains 99214: "This code represents the second highest level of care for established office patients. This is the most frequently used code for these encounters. Internists selected this level of ccare for 47.41% of established office patients in 2014. The Medicare allowable reimbursement for this service is $108.13 and it is worth 1.5 work RVUs. Usually the presenting problems are of moderate to high severity." Adding:

The documentation for this encounter requires TWO out of THREE of the following :

1) Detailed History
2) Detailed Exam
3) Moderate Complexity Medical Decision-Making

And there is the rub. Guess what can make one visit 'Low Complexity' and another 'Moderate complexity?'

A prescription.

That's right. A doctor prescribing a drug for you is the difference between billing 73 bucks and billing 108 bucks.

Peter R. Jensen, MD, CPC writes in Coding “Routine” Office Visits: 99213 or 99214? -- "...if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk."

Dr. Jensen opened the above piece with, "Many of us may be shortchanging ourselves by reflexively coding a routine office visit as 99213 when the clinical circumstances of the encounter justify the higher-level code."

President Donald Trump and Speaker Paul Ryan -- ever wonder why we see so many drug commercials? That's right. So patients recall them.



How many folks heading into a doctor's office 'may ask the doctor if XYZ is right for them' when XYZ treats everyday issues like light anxiety, occasional sleeplessness, or, say, constipation?

We'll guess it's a lot. Bam. A drug is prescribed and hello 99214. How about a one month follow-up visit for golfer's elbow (which requires rest) and the doc, after the patient says it is a bit better but it is still sore, asks, "Would you like me to prescribe you some ibuprofen or some Voltaren Gel?" Sure, why not? Bam, 99214.

Now not only is Medicare, or the health insurer, etc. on the hook for a more expensive office visit...we're also now looking at a prescription pick up and drug reimbursement $$ to boot.

How much is this costing patients gentlemen? And how can it be policed? Because it has to be or health care will continue to be a big huge problem.

[E/M University & AAFP]

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