Don’t Default to CPT® Code 99213 for “Routine” Visits

Here’s How to Support 99214-15 When They Are Appropriate

Did your med school education include formal instruction in using CPT (Current Procedural Terminology) codes?

If you’re like most practitioners, it didn’t. But Dr. Carolyn McClanahan’s did.

She wrote for Forbes about a billing class she took during her residency: “We were told that most patients should be 99213, so try to hit that level most often. Of course, we were instructed to not sell ourselves short if we performed enough to charge a level 99214 or 99215.”

Dr. McClanahan doesn’t think much of the CPT® code reimbursement system. “It would be great,” she wrote, “if the doctor could see the patient, document what needs to be documented, and get paid based on quality of care instead of quantity of activity and documentation.”

Is the system perfect? Absolutely not. But at MDCodePro, we’re convinced “quantity of activity and documentation” aren’t at odds with the quality of care—not if you’re doing them the right way. In fact, they’re essential to it.


Why Many Doctors Lack Confidence When Coding 99214 and 99215

As Dr. Alexander Stemer points out in one of his MDCodePro video lectures, doctors tend to learn the full extent of patients’ problems only as a visit goes on.

What begins as your established patient’s “routine” or “follow-up” office visit can legitimately become something much more complicated. This development requires you to use a higher degree of medical decision-making (MDM).


So why would you go into a visit “trying to hit” a 99213 reimbursement when the patient’s risk and your MDM’s complexity may legitimately call for something higher?

Why treat those higher codes as an afterthought when today’s patient population is aging and presenting with more chronic health problems? In fact, over 50% of older adults live with three or more chronic diseases, according to the American Geriatrics Society. “Multimorbidity” is a common reality, especially among Medicare beneficiaries.

This situation means more cognitive labor for you. You must review more data, consult with more providers, weigh more possible diagnoses, and consider more courses of treatment for your patients.

Shouldn’t your professional habit include enough “activity and documentation” to make sure you’ve captured each visit’s complexity in your note and haven’t missed anything important?

And shouldn’t you be fully reimbursed for the services and procedures you provide, if your documentation reveals they actually warrant code 99214 vs 99213—or even, in some cases, warrant 99215? Why should you forfeit revenue you’ve legitimately earned?

Yes, we’ve heard valid concerns about some doctors overcoding to grab more money. So has the government, including cases where these very codes are at issue.

Physicians’ combined use of codes 99214 and 99215 climbed 17% from 2001 to 2010. And while the OIG didn’t determine whether that increase was inappropriate, HHS’ report on improper Medicare payments in 2017 found a 3.9% overpayment rate for code 99214 (total projected overpayment: $309,233,628), and a 14.3% rate for code 99215 (total projected overpayment: $148,691,729).

Findings like those coupled with the important aim of cracking down on fraudulent coding may make you hesitant to claim reimbursement at the 99214 or 99215 levels. We understand. The pressure to fall in the middle of a bell-shaped code curve in hopes of avoiding a third-party auditor’s unpleasant scrutiny feels real.

But we also know you’re a conscientious, responsible practitioner. So is there a way you can conscientiously and responsibly code one, even two levels higher than 99213 when appropriate?

There is. And the MDCodePro methodology, validated repeatedly in audits, is what you need to make it an integral part of your established patient office visit routine. Our method will equip you to code 99214 and 99215, when legitimate, with confidence.


Support Any Appropriate CPT® Code Reimbursement with MDCodePro

The CPT® code 99213, code 99214, and code 99215 requirements are that two of a visit’s three elements—history, physical, and MDM—correspond to the complexity/risk score associated with the code you assign: low for code 99213, moderate for 99214, and high for 99215.

To help you meet the “two of three” requirement, MDCodePro suggests you make comprehensive physical exams your standard procedure. It’s the exam standard you learned in med school, and it’s still your best bet for the quality care and regulatory compliance today.

When you’re properly giving and charting comprehensive exams, you’ll have the documentation you need when your MDM rises to a high level of complexity. You’ll have no trouble meeting the code 99215 standards.

Yes, you’ll have more information than required for codes 99214 and 99213, but you’ll always only code to the level of complexity/risk, and you’ll have peace of mind knowing you’ve thoroughly examined your patient and haven’t missed any pressing problems.

Does giving all your established patients a comprehensive exam when they visit sound like a lot of extra work? Don’t worry. It’s not. Let MDCodePro show you how easy it is to do and document comprehensive exams. It’s a small change that could lead to big changes in your patients’ outcomes and in your medical practice’s profitability. Sign up for your MDCodePro subscription today.


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