Simplifying Office Coding

It’s been a couple of years since the new office-based codes were redefined and revalued by the AMA and CMS.  Now that we are all getting more familiar with the criteria, I want to review and hopefully simplify office coding levels.

My simple way of looking at this is as follows:

• Level 2 (99212/99202): The patient could have asked their mother.
• Level 3 (99213/99203): The patient could have asked their family doctor.
• Level 4 (99214/99204): The patient came to the right person.  I’ve got this.
• Level 5 (99215/99205): The patient is really complex and it’s going to take a lot of effort to care for this patient.  I might need some help with this patient.

Now that office billing doesn’t depend at all on history or exam, it is very important to understand how medical decision-making (MDM) works according to payers in order to get paid fairly. Medical decision-making is divided into three parts: Number of Diagnoses, Amount/Complexity of Data and Risk.

The number of diagnoses is often the driver of the other two parts so understanding this one is probably the most important. Level 2 is self-limited or minor problem. It’s rare for me to see this patient—they usually are seen by a nurse practitioner or their family doctor. Level 3 is one stable chronic condition (follow-up for menorrhagia that is going well with treatment) or an acute uncomplicated illness or injury (yeast or BV infection). Level 4 has quite a few criteria but the ones I look at are the new problem with uncertain prognosis (new onset bleeding of any sort) or exacerbated chronic illness (condition where initial treatment isn’t working). Level 5 is a situation where there is a threat to life or bodily function.  Most of those patients, I would see in the emergency room (also an outpatient arena) not in the office.

The amount of data can also be simplified. Level 2 is one or less items (either labs, imaging, or independent history). Level 3 is two items, level 4 is three items and level 5 is four items. Of course, the text from the AMA is more than this, but this is my simplified version.

The four levels of risk are also pretty simple. Level 2 is really nothing—rest, ace wrap, heating pad. It would be rare, if ever, to see this patient. If they are there to see a physician, we can offer more. Level 3 is over the counter medications or minor surgery (0-day or 10-day global) with no risk factors (placing an IUD, office hysteroscopy, ordering a saline infusion sonohystogram or hysterosalpingogram). Level 4 is prescription medications, minor surgery with risk factors (and doesn’t every patient have risk factors?) or elective major surgery without risk factors. Level 5 is the patient who needs surgery but has serious risk factors for surgery.

When this is all put together, you only need two of three. Thus, you don’t need to meet a level 4 in all three areas. Most of the patients I see for a new complaint will easily be a level 4. Follow-up patients will almost always be a level 3 (unless the treatment isn’t working, then it bumps to a level 4). I have a few level 2’s and the occasional level 5 (mostly based on time, not medical decision-making). It’s important to look at your coding histogram (the insurance companies, compliance department, and CMS are looking).  For a busy practice, you should have similar numbers of level 3 and level 4 billing. If you don’t, it would be good to have someone audit 10-20 charts to see what you are missing. The value difference between a level 3 and a level 4 visit is substantial and will absolutely affect your bottom line. Happy Coding!