If you’ve ever had a Medicare payer or internal compliance audit you’re probably familiar with the term “over coded,” or even “under documented.” While these terms are not synonymous, they do indicate a deficiency in your coding and documentation processes that could pose problems in the future if they aren’t addressed. Here’s what you should know about discerning between and documenting two of the most commonly used care codes. 

What’s the difference between over coding and under documenting?

These two errors actually reflect different process issues. When a claim is over-coded, it means that the chart doesn’t seem to support the required work in these three areas:

• Medical history
• Physical exam and/or review of systems
• Medical decision-making

Of these, medical decision-making (MDM) is the driving factor. Does the patient’s presenting problem (sore throat, for example) require a full physical examination? Are there significant risks for complications? Once you’ve addressed the MDM, it guides the scope of the other two components. 

Under documentation, however, means that the MDM evidenced in the chart isn’t supported by the history and exam detail; in other words, there is significant doubt about the extent of the MDM. 

What are the documentation requirements to support 99213 vs 99214?

It’s important not to assume that it’s the volume of documentation that supports the care code, but rather the detail that supports the medical decision making process. 

Sample criteria for a level 3 care code

The characteristics of a presenting problem for this level include:

• One stable chronic illness or condition, or
• Two (or more) self-limiting conditions, or
• One acute but relatively uncomplicated illness or condition.

In order to justify this level of coding, the provider should document the following elements:

• A relevant entry in the HPI.
• Review of systems related to the presenting problem.
• A problem-focused but expanded physical examination. 

It’s important to remember that patients who are accurately coded with a level 3 encounter are really not very ill, which makes it rather surprising that over 50% of Medicare patients are coded at this level for most office visits. If your providers are routinely selecting 99213 because it’s “in the middle,” be sure to double-check the MDM, because in many cases, patients with several chronic conditions and potential complications require MDM that rises to level 4. 

Sample criteria for a level 4 care code

An encounter may justify a level four if one of the following conditions apply:

• A new complaint with the potential for exacerbation or serious complications. 
• At least three chronic problems or conditions.
• One new condition or three existing conditions that require prescription medication (or refills).
• One stable and one uncontrolled condition that requires medication management or adjustment. 

Documentation should include the following elements to match the level 4 designation:

• A detailed history including chief complaint (can be included in the HPI, which should also include four distinct elements and/or status of existing chronic or inactive conditions).
• Past medical, family, social history including problem list and/or link to medication list. 
• A detailed exam with at least five organ systems. 

In addition, the chart should reflect moderately complex MDM with at least two of the following:

• Exacerbation of a chronic illness (mild to moderate).
• New problem diagnosis.
• Prescription drug and/or side effect management.
• Multiple diagnoses and/or multiple treatments or medical management options. 

You can also document time guides to support you care codes; a level 3 correlates to 15 minutes and a level 4, 25 minutes, over half of which must be spent counseling the patient (HPI and PE don’t count as counseling). For example, “I spent 25 minutes with Ms. Smith, over half of which was spent discussing surgical options to treat her condition.”

If you’re not sure about coding and documenting your office visits, or how to maximize your reimbursement, contact the billing professionals at M-Scribe today for a free consultation.

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