435meet criteria in my book. However, I personally do not think medication renewal
qualifies as drug management, but others do.- The level 4 physical exam in the 95 system. Level 3 exam is easy with one bullet
(i.e., NAD, vital signs as below or normal affect – yeah I know it is ridiculously
little). Level 5–8 organ systems – one bullet each. But the rule makers couldn’t
be clear for level 4 – it is listed as two total systems, one system detailed. I inter-
pret this as one system with one bullet and another system with four bullets (e.g.,
general – NAD, vitals as below, GU penis circ’d (1), urethra normotopic without
discharge (2), testes bilaterally present without masses (3), and cord structures
present without varicocele (4)). To me, this seems very straightforward, but to
our compliance and billing section, it is not.
Let me elaborate (I know you don’t have a choice). There are two systems – one
created in 1995 and the other in 1997. My understanding is the 1997 system was
created to help specialists (like psychiatry) be able to charge for a level 5 exam
without a stethoscope by being superduper thorough on certain systems (for psy-
chiatrist – psych and neuro systems related... please, tell me about your mother).
Medicare states you can use one or the other in a note but should not combine ele-
ments of the two in the same patient’s note. I personally toggle between 95 and 97 in
clinic for whatever is easiest for that particular patient encounter. However, my
previous compliance people taught me only the 97 system?!? You really should be
asking why at this point. The answer they give is that there is less ambiguity. Now
take a guess which of the two systems is much more labor intensive and hard to
remember. Yup, it is 97.
- Billing on time – The thresholds for billing on time for an E3 and E4 visits are
15 and 25 min, respectively. So if you spend 21-min face-to-face with the patient
(> 50% in direct patient counseling), should you bill E3 or E4? This is up for
debate; I’ve had some experts tell me you should bill E4 (have to eclipse halfway
point), but others vehemently disagree (need to hit the entire 25 min).
I still am unaware of a resource where specific billing questions like these can be
answered. Institutions tend to set their own policies for various reasons. When I
previously asked our billing people, that person will ask their supervisor. The super-
visor has the same information you do (not some magical book with the specific
answers). Try calling CMS people, and they will refer you to the document that
creates ambiguity in the first place. So, ultimately for matters of dispute, it’s up to
interpretation of vague phrasing. This is why you can argue with the people who
audit your notes, as long as there is some logic and justification why you picked
what you did. Remember to fall back on medical risk as the trump card for what to
decide, and you’ll be fine. In billing courses I’ve attended, expert billers in the same
room often come up with different answers on how they would bill the same encoun-
ter documentation.
Important point on ambiguity – I sometimes struggle with how to bill between
levels and if unsure will err on the side of caution and bill the lower level. This is a
23 Evaluation and Management Documentation, Billing, and Coding