Medicare can pretty much do whatever they want and audit pretty much just about whatever they decide to do. They have been doing this CERT audits on 99215 and other high-level E/M codes.

One year, it may be a 99214 with a 99233 or it may be the 99215. They kind of alternate that. But the point of doing these CERT audits is to make sure that the documentation is there. It isn’t always so much that they’re seeing a high level of 99215s come through to do that, but having said that, these EMRs actually code higher than the documentation supports.

They are seen more and they are auditing more.

Why Does Medicare Conduct CERT audits on 99215?

The CERT audits are random. They want to make sure that documentation is supporting the code. Unfortunately, in office settings, not all coders are well-versed in E/M leveling and 99% of the time it’s probably the physician doing it or it’s the EMR that’s doing the codes. It isn’t going to be always accurate. That’s one reason you got to have somebody in your office who can do E/M leveling, who has gone and studied that a little bit more.

If they down-coded, then they’re saying you did not perform a 99215, which will be the point of down-coding, right?

What Does “Down Coded” Mean?

Have you ever encountered using 99215, then Medicare sends it back? They just tell you, “No, we think you just down coded to 99213.” What they’re saying is, they’re not going to pay your 99215. They’re going to drop it down to a lower code and pay that because your documentation supports that.

It’s called down-coding, when you don’t get the big bucks, you just get the medium bucks. Well, if we’re talking about Medicare.

Why was your 99215 down coded? Is it because of who is coding the visit or the time spent? There are MDs who spend 45 minutes or more and cover multiple systems and problems. Does it matter?

It doesn’t necessarily mean that your physician was doing anything wrong, it just means you got the luck of the draw to do that. Unless they’re coming back and telling you that you are wrong, just send in your documentation and not worry about it so much.

Who is coding the visit? Is this a coder or is this a physician or are you letting the EMRs do the coding? Either or we may not be well-versed in leveling visits and the documentation that is required. The time spent shouldn’t even be a consideration unless it is in the documentation, how much time was spent doing an exam, how much time was spent doing counseling or chart review, or additional testing. In order to use time, that has to be after the exam is done. Time is not your first consideration because, number one, it’s not even one of the key components you should be looking for.

Multiple systems and problems might have been covered but check how is the information documented? If you’re getting down coded, then you’re not documenting all of the work that you feel like you’re doing. Make sure that you take a look at that documentation.

For a 99215 to even be billed, you need to have that 2 out of 3 components. Again, time is not going to be one of them. It plays a key in it but it’s not one of your three key components.

The first component that you need to take note of is a comprehensive history.

#1: Comprehensive History

What we do need for that 99215 is a comprehensive history.  This is going to include the Chief Complaint. You have to have an extended History of Present Illness(HPI), which is four or more elements.

Then, make sure you have a review of systems.

#2 Review of Systems

Review of systems is not the exam, so don’t get confused nor interchange these terms. You need at least ten reviews of systems and you need to complete Past Medical, Family, Social History(PFSH) in order to have a comprehensive history. That’s quite a bit in itself. For the exam, if you’re using that as one of your two key components, in order to have a comprehensive exam, you need a general multisystem exam or the complete exam of the single orbit system in which you need eight or more organ systems touched and documented.

Last but not the least is medical decision making.

#3 Medical Decision Making

Medical Decision Making has to be of high complexity. It has to have extensive management options or diagnoses. It has to have an extensive amount or complexity of data – meaning, we needed to have a lot of lab work or some x-rays, MRIs, CAT scans, other types of testing that we are looking at, ordering, and reviewing. Then, the high risk of complications or morbidity has to be there. It has to be documented. This does not necessarily mean that you need five or six diagnoses. You can have just one.

The patient could have lung cancer or liver cancer, any type of cancer and we could actually make a visit for 99215, but that documentation has to be there and it has to be in that chart. If you’re using an EMR, what are you clicking on to make that documentation stand out for that 99215? Once again, time cannot be your first factor in there to do that.

To sum it all up, Cert audits are not just because they can and they don’t like to pay a lot of money to bill a 99215. But really and truly, they’re looking at it because physicians are submitting a 99215 and there’s no documentation to support that. It’s too hard to get. It should not be the rule. It should be the exception.