Recently, I've had the opportunity to accompany my parents on their visits to the doctor's office.  Until sitting in on an encounter of that sort, I underestimated the complexity and time-consuming nature of senior citizen encounters. An elderly patient's status or history can be a moving target. Medically, an already established elderly patient that visits your practice regularly can often present like a new patient altogether with new symptoms, complaints and organ system problems. Add to that the issues of drug interaction and their social situation in regard to family and care-takers-or lack thereof-and the result can be a very long time-consuming encounter.

Very few of my clients, even those with a large Medicare patient base, utilize the 99215 or the other prolonged service codes. Many of the doctors refuse to bill a 99215, for fear that doing so would automatically invite a third party payer audit, which could open a "Pandora's Box" on other billing issues. Consequently, it is not uncommon for doctors to intentionally bill at a level lower than the service they provided in an attempt to "fly under the third party payer radar." 
Not every Medicare patient will automatically justify a level 5 visit, but it is unfortunate that many physicians intentionally shy away from this high level of service due to fear of audit. While their fears may be understandable, the level 5 codes, whether for new or established patients exist because payers assume physicians will have extensive and complex encounters of this sort. 

The level 5 Code
The level 5 code should not be the proverbial "third rail" and by simply breaking down the requirements for a 99215, your practice might become more comfortable with billing such interactions. 

For coding purposes, there are three broad parts of your encounter that you must document: 
1. History - includes the History of Present Illness (HPI), Review of Systems (ROS) and Past/Family/Social History
2. Physical Exam
3. Medical Decision-making

With an established patient visit, of the three criteria above, you only have to satisfy two. For example, if you have a level 5 history and a level 5 complexity of medical decision-making, but a level 3 exam, and the patient is an established patient to your practice, you are able to throw out the lowest of the three and take the top two. Of those two, the lowest of the two would determine the overall visit level, so in this case, with a level 5 history and a level 5 complexity of medical decision making, you could bill a 99215 for that established patient. 

Components of each criterion
HPI - In order to achieve a level 5, you must document four or more factors regarding the illness or pain as to such things as location, duration, severity, quality, associated signs and symptoms, modifying factors, timing and context. If a patient comes in complaining of abdominal pain and you document the pain's location, duration, quality and severity, then that's a level 5 HPI. As an alternative, you can document the status of three or more chronic or inactive conditions and qualify for a level 5 HPI.

ROS - For a level 5 review of systems, surprisingly, you must document a review of only two systems.

PFSH - Of the personal, family or social histories, a level 5 visit requires that you document two of the three.

Physical Exam - Of the 14 Body System/Areas (constitutional; eyes; ears/nose/mouth/throat; neck; respiratory; cardiovascular; chest/breasts; gastrointestinal/abdomen; genitourinary; lymphatic; musculoskeletal; skin; neurologic; psychiatric) you must document examination of at least nine of the body systems, and within those nine systems, document at least two exam elements from each.  Example:  "Respiratory-Lungs clear; normal to palpation" would satisfy two exam elements in one body system.

Medical Decision Making - The three elements of medical decision-making include number of diagnoses or management options; amount and/or complexity of data to be reviewed; risk of complications and/or morbidity or mortality. Of these three elements, only two of the three must be documented. For a level 5 established office visit, you must document a high complexity encounter. 

This could be achieved by encountering a patient who presents the following:

• Number of Diagnoses or Treatment Options: a new problem to you for which additional workup is planned.
• Amount and/or Complexity of Data to be Reviewed: review and/or order of clinical lab tests; discussion of tests with performing physician; review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider.
• Risk of Complications and/or Morbidity or Mortality:  One or more chronic illnesses with severe exacerbation, progression or side effects of treatment.

And don't forget, of the above three elements of medical decision-making, only two must be met.
After reviewing the above criteria, keeping in mind that of the three elements of medical decision-making only two must be met, you may realize that you have treated a number of patients fitting the level 5 criteria. By billing those patients at a lower level, you are negatively impacting your bottom line, leaving money on the table that you are entitled to bill and collect. Assuming you have properly documented the visit, the Medicare fees escaping your practice due to intentionally undercoding for 99213, 99214 and 99215 are $66.74, $99.93 and $134.95, respectively (2010, National Values).

In my business, we frequently hear the complaint "I'm working harder these days and making less" and a component of those frustrations could be intentional undercoding. By learning how to justifiably document and bill a code 99215, you could dissolve your fears of a third party payer audit and reclaim lost revenuean absolute must in today's challenging healthcare environment.

David E. Hunt is president-elect of the National Society of Certified Healthcare Business Consultants
(www.nschbc.com) and principal of Doctors Management Services and Parrish Moody & Fikes, p.c. (http://pmfwaco.com/). He's a CPA and certified healthcare business consultant.