Physicians should be able to care for patients without the fear that they are losing money. Undercoding is a significant contributor to lost revenue and is no small issue. Some physicians undercode because they underestimate the service they provide, while others undercode with hopes they will avoid an audit. Regardless of the reason, the potential for reduced revenue can be significant.
According to Medicare, the allowable difference between 99213 and 99214 is $36.77 per visit. If you multiple $36.77 by the number of Evaluation and Management services provided, the dollar amount can grow significantly. For example: If a physician sees 800 Medicare visits and undercodes half of them, about $14,700 in revenue would be lost by a simple billing error.
The requirements for these two billing codes are:
Level 3 Established Office Visit (99213)
This level of care is located “in the middle” of the coding spectrum for office visits with established patients. The documentation for this encounter requires TWO out of THREE of the following:
- Expanded Problem Focused History
- Expanded Problem Focused Exam
- Low Complexity Medical Decision-Making
Or, 15 minutes spent face to face with the patient if coding is based on time.
Level 4 Established Office Visit (99214)
This code represents the second highest level of care for established patients. The documentation for this encounter requires TWO out of THREE of the following:
- Detailed History
- Detailed Exam
- Moderate Complexity Medical Decision-Making
Or, 25 minutes spent face to face with the patient if coding is based on time.
Ask yourself, is your practice losing money? Or better yet, ask us. Contact us today.
Click below for a quick reference of E/M codes 99211 thru 99215.