SAN FRANCISCO — Many physicians who manage patients with chronic hepatitis C could increase their incomes simply by paying closer attention to coding, Dr. Imtiaz Alam said at the annual meeting of the American Association for the Study of Liver Diseases.
“Physicians tend to play it safe” when billing for hepatitis care by choosing Evaluation and Management (E&M) codes appropriate for visits with little complexity in the medical decision making, said Dr. Alam, medical director of a private hepatitis center in Austin, Tex.
Instead, visits with patients being treated for hepatitis C almost always should be coded at levels of moderate or high complexity, he said.
The difference can add up. For visits with established patients, Medicare reimburses an average of $38 for E&M code 99212 (the least complex medical decision-making), $52 for code 99213 (low complexity), $82 for code 99214 (moderate complexity), and $119 for code 99215 (the most complex decision making), he noted.
If there is a $30 difference in payment between codes 99213 and 99214, and a physician undercodes seven visits per day as 99213 even though they qualify as 99214, that would lead to a substantial loss of income—$1,050 per week, Dr. Alam said.
A common mistake is to assume that physicians must spend more time with more complex patients to qualify for the level 4 or 5 codes, he suggested. “Coding levels have little to do with how quickly or easily you come up with a plan of care,” but rather reflect the physician's effort and the level of risk to a patient in implementing a plan of care, he said.
An experienced hepatologist may spend only 10 minutes with a hepatitis C-infected patient and still determine the plan of care, Dr. Alam noted.
He described other conditions that typically qualify for codes 99212–99215. An office visit to provide reassurance to an established patient with an irritated skin tag would be code 99212. Code 99213 might be used for an office visit with an established patient with stable cirrhosis of the liver. “But how many of your hepatitis patients are stable? I suspect most of them are not,” he said.
Code 99214 would be appropriate for an office visit by an established 45-year-old patient on immunosuppressive therapy for rheumatoid arthritis. “How is that different from your hepatitis C patients who are on therapy?” he asked. Code 99215 might be used for an office visit with an established 36-year-old patient who is 3 months post transplant and is developing peripheral edema, increasing blood pressure, and progressive fatigue. “I suspect that many of your hepatitis C patients on interferon therapy are probably having many issues,” Dr. Alam said.
For office visits by new patients, there can be a $38 difference between coding for 99244 (moderate complexity of decision making) and 99245 (the most complex cases). Code 99245 would be appropriate for a first visit for initial evaluation and management of Cushing's disease. “How is that different from your initial evaluation of hepatitis C when you're going to consider them for therapy? I don't believe there's any difference,” he said.
The key to feeling comfortable with appropriate coding is to document the steps needed to qualify for those codes, he added. New patient visits require a history, exam, and medical decision making.
Only two of those three are required for visits with established patients. An exam isn't necessarily essential if the patient fills out a Review of Systems form and the physician documents height, weight, and blood pressure and engages in the appropriate level of medical decision making. For higher-complexity coding, the physician also should ask about changes in family or social history (such as alcohol consumption).