The CPT code 99214, if used correctly, can be a great revenue enhancer for the provider. There are many providers who do not utilize this code to its fullest potential. By only using CPT code 99212 and CPT code 99213 many providers are losing thousands of dollars in legitimate revenue yearly. However, with the correct use of the CPT code 99214 you can assure yourself the revenue that you rightly deserve.
Insurances are Glad To Pay You Less
Medicare and other Insurance companies are happy to pay the lesser amounts to providers if they (the providers) are willing to under-utilize the CPT code 99214. The key to using this code properly is to understand the proper use and the components required to fully capture the maximum out of all of your encounters. As a provider, you will be rewarded the fruits of your labor when you take the time to learn the components of this code and use it properly.
When you consider CPT code 99214 it has a higher return rate linked to it, however, it must fall under the purview of a moderate complexity to a high severity problem. The physician, if using time as a factor must have spent at least 25 minutes in a face to face scenario with the patient. However, the time component is only a guide and not completely required if the components are included in the visit and the required medical necessity is present. The physician must be able to furnish the two or three areas which include history, physical exam and medical decision making with the proper documentation when filing for the CPT code 99214.
The patient encounter, composed of a detailed history, detailed patient exam and moderate complexity in the medical decision making will justify the use of CPT code 99214 as long as the medical necessity is apparent.
Document, Document, Document
For example, you have an established office patient with hypertension, diabetes and a history of dyslipidemia who you are seeing on follow up in the office. Under the 1997 guidelines you can use three chronic and stable conditions to qualify for the higher code within the history component.
Document the medications and the review of systems along with the proper past medical, family and social history and the first component is met. Document the proper physical exam using appropriate organ system approach six areas with two bullets each and you have met the requirement for the complexity on this area.
At this point, technically you have reached the level 4 criteria since there only needs to be two out of three components required for an established patient.
However, we feel that it is difficult to not have a medical decision making component so we include that into our progress note. You can document the lab results for the patient and further solidify the visit to qualify at the higher code. As long as the medical necessity is present to justify the work done during the visit the coding can be at the higher level.
Most providers will code the example as a CPT 99213, however, the qualifiers are present for the higher 99214 code.
That being said, evaluating three different medical problems such as Hypertension, Diabetes and Hyperlipidemia, using the 1997 rules, you have met the medical necessity component as well, due to the need to monitor these diseases and help the patient with his/her control.
Taking the time to learn the proper criteria needed to code the encounter will enable you to reap the rewards for the rest of your career. In a day and age where we are facing potential cuts in the reimbursements for the services we render, we owe it to ourselves to stop giving away the revenue we deserve. The moment you have mastered the art of the using the proper CPT codes you will be able to record them accurately and get the money you deserve.