CPT Code 99214 Evaluation

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23rd Sep 2019 Health Reference this

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Introduction

It is vitally important to use the correct billing CPT code 99214 for Evaluation and management coding when establishing a new patient visit, this can increase profits through Medicare reimbursement. The code 99214 can be is used when a doctor or physician as spent at least 25 minutes of his or her time face-to-face with a patient.

CPT Code 99214 On-line

The CPT code 99214 is assigned too many hospitals or clinics that meet the terms of the requirements to include:

  1. The patient has been seen previously and is considered not to be their first visit.
  2. Visit must be outpatient and not to include a night stay in the hospital.
  3. It must surpass two of the following three points:
  1. A complete history
  2. A complete medical examination
  3. Medical decision that involves reasonable complexity.

Reasons for the patient visit can range from moderate to severe and needs to include the physician and patient interaction a total of 25 minutes face-to-face.

Medicare along with other insurance pay less money to the physicians if they are in agreement with under coding by using CPT code 99214. The physician must understand the importance of using the code correctly, and the mechanisms necessary to capture most of the doctor’s encounters.  The CPT code 99214 have a greater return rate but falls underneath a moderate complexity to a severe problem.

Medications, review of systems, past medical, family and social history are the first component that needs to be met. Physician needs to document the appropriate medical exam using the right body systems by focusing on six areas to include two bullets to meet the obligation for the complexity of this area. Medical decision-making component is included in the progress note, and you can also include the laboratory results for a higher code, but the physician have to include the medical need to justify the services performed during the visit so the code can be at a higher level.

Lastly, doctors will code using CPT code 99213, but the qualifiers shot for the higher CPT 99214 code. By following the 1997 rule focusing and evaluating the three medical patient problems such as high blood pressure, diabetes, and High cholesterol the physician has met the medical requirement as well as monitor these illnesses to help the patient monitor or control the disease. Medical Billing and Coding Online. (2011-2015. Para. 1-15)

CPT Code 99214 Individual State

CPT code 99214 can be used hospital or clinic visit for medical and psychological health illnesses by patients who are already established as a patient.  CPT Code 99214 resembles CPT Code 99215 and can be difficult to distinguish between the two billing choices. Using CPT code issues the second maximum level of care and considered a level four code. Code 99214 can be used in-office or outpatient setting. You can get compensated more for Code 99214 which has become a standard of the Affordable Care Act. Using the wrong code can result in an audit.

Many health professionals can bill with CPT 99214. Billing with CPT Code 99214 requires two of the three components such as a full interval health history, complete examination and a reasonable complexity medical decision making this code should be used for face-to face time with the provider spending greater than 25 minutes with the patient and normally of a moderate to high complexity, when this level of care is required billing becomes vitally important allow the doctor to bill at a higher rate by using behavior tools to determine and measure physiological disorders that may exist.

When using the billing CPT Code 99214 and 99215 directly with the patient at the time of the visit is the basis for compensation. CPT Code is reimbursable for $107.20 a piece per patient and Code 99215 reimbursable for $144.80 a piece per patient totaling a difference in excess of $37 for appointment per patient.  Ash, A. (2017. Para. 1-16) 

3 traditional indemnity insurance

 According to American Academy of Dental Sleep Medicine. (N.D. P. 3-4). In America health insurance is provided via private or public health insurance plans. Employers offer private health insurance for the employee and through entitlement programs funded by federal and state government public health insurance is offered. There are several types of insurance to include:

Private Medical Insurance

Fee-for-Service Plans known as traditional Indemnity Plans

HMO, PPO, POS known as Managed Care Plans

Medicare, Medicaid, Tricare, CHIP known as Public Health Insurance

Traditional indemnity plans are health indemnity insurance plans in which the insurance provider repays the covered party regardless of where and who the patient seeks medical care.

An agreement amongst the covered party and insurance carrier where insurance is given to the covered party built on specifications of the insurance policy is known as indemnity plan, and coverage can be different for each recipient. Indemnity insurance plans provide plan patients with flexibility about which physician to visit with limits on the amount that will be compensated for services provided.  Medical cost and compensation ranges from a per-day or percentage that include exact charges for the cost of the medical expenditures.

There are 3 formulas used to determine the benefit amounts actual charges, percentage of actual charges or indemnity.

A medical indemnity insurance plans is charges the insurance pays for the actual amount of charges they the patient acquired at the time of service, with no maximum amount for expense providing the patient has a receipt for the services the doctor completed, reimbursement will be given to patient for their medical cost.

The patient is accountable for the balance between the medical expense and amount paid for by the insurance carrier under the medical indemnity insurance plan that help pays a portion of the charges.   A portion of the charges are normally set at 80% with medical cost at 100, the insurance would cover $80 with the patient paying the balance of $20 copay or deductible.

A medical indemnity insurance plan that is paid by the indemnity is set by the underwriter which pays a set amount each day of coverage and not based on reimbursement for health care cost, if the day-to-day rate surpasses the total of the healthcare cost, the carrier will only pay the cost of the health care cost.

Reimbursement under the indemnity plan patients will get an invoice from the health care professional for the services performed and patient responsible of the cost, a claim such be submitted to the insurance provider in which they will repay the patient directly.

Accounts Receivable Benchmark

As suggested by the Practice Management Resource Group. (2019. Para 1-8)   account of charges that wasn’t poised yet is called Account Receivable Summary and can be measured in many ways to include patient, insurance plans and payor.  This report is used widely by many health care organizations to collect negligent accounts by patients on a monthly basis The AR ought to be reported as a summary by payor class from the perspective of billing and receivable management process. Creating an AR summary by the payor class determines if the AR in each class is suitable for the payment in that payor group.  

When analyzing the AR summary the payor class needs to be looked at to see if the pattern of AR totals by time grouping to include 30, 60, 90, 120 days or greater. One more factor in evaluating the AR summary and the age of accounts the financial manager must understand how the computer system ages accounts.  

Sample Accounts Receivable summary by Payor class: 

Payor

Current

31-60

61-90

91-120

121-150

>150

TOTAL

Self-Pay

$16,375

$9,285

$12,778

$11,768

$10,756

$29,678

$90,340

Indemnity

$7,155

$8,226

$2,809

$1,698

$1,276

$9,845

$31,009

FFS Managed Care

$82,928

$66,582

$23,810

$9,780

$2,650

$276

$186,026

Workers Comp.

$3,242

$4,218

$2,395

$1,472

$534

$2,964

$14,825

Medicare

$203,673

$183,214

$23,851

$9,365

$2,186

$86,720

$509,009

Medicaid

$12,214

$14,634

$9,621

$7,215

$1,378

$18,942

$64,004

Medi/Medi

$10,576

$8,265

$1,763

$935

$0

$0

$21,539

TOTAL

$336,063

$294,324

$76,927

$42,233

$18,780

$148,425

$916,752

  1. Medicare outstanding charges greater than 90 days and over 150 days proposes that Medicare patient balances ran or the secondary insurance are not being billed or collected properly. Another option is that the contractual allowance wasn’t properly written off.
  2. The self-Pay section shows that charges are not being tracked, or not made correctly.
  3. In the Medicaid section AR greater than ninety days indicate if your state Medicaid system  is slow with the funds there should be no AR over 60 days in this section, but if charges show a pattern of monthly charges of less than 30, 60 and 90 days in the sections are equal.

Improved reimbursement of 20%

According to an article by Brown, B. (2014. Para 1-32). Unless the hospital is high performing the hospital money is a risk with the value-based reimbursement. In order for the hospital to become high-performing it will need to focus on risk-adjusted mortality, readmission rate and lowering cost. These goals can be accomplished by adhering to the Center for Medicare and Medicaid 2015 ruling and Hospital inpatient Prospective Payment System value-based reimbursement which will affect healthcare in the United States.    

With the value-based reimbursement a study was conducted and showed that doctors reimbursement was at 6 percent as suggested by the 2013 metrics and has since doubled the 3 percent since 2012. The new regulation call for doctors to meet the quality cost standards to avoid a possible penalty and cost and quality adjustment effective in 2017. The penalty for failing to comply with the Physician Quality Reporting System can range from -4.0 percent.

Medicare want physicians to provide higher quality and coordinated care at a lower cost. To achieve this outcome hospitals bundle payments applications for a total period of care to include financial and performance accountability. Physicians tend to focus more on bundling payments.

To improve the reimbursement of 20% percent or more hospital needs to focus more attention on:

  1. Obtaining information from the storage towers that we generated, so we can try to improve care and lower costs. By using an analytic system the hospital can track it performance and make improvements based on key quality interventions that are necessary. Hospital also can use electronic data warehouse to see where discrepancy exists and the source. This is serious because removing discrepancies and waste can increase the effectiveness of Medicare.
  2.  Sharing knowledge of a valued base system and the effects. Hospitals can consult other organizations to ask for help to reach to desired goals.
  3. Improve hospital plans by doing an assessment for the year following up to 5 years. This can be done by determining the hospital present situation, deficits, and plans to overcome the deficits.

Healthcare has faced many chances and challenges to be able to endure the value-based reimbursement system hospital will have to access their information to conclude where they can make changes.  

When evaluating the payer mix if the account receivable is more than 20 percent the financial manager needs to see what can be done it is vital to make sure the hospital revenue is not dependent on only one or three payers. Health maintenance organization pay little and workman compensation can take up to 90 days from the time the patient was seen for care, so if the hospital only had one to three payers the account receivables greater than 120 days can cost the hospital.

When Blue Cross and Blue Shield or United Healthcare being to cut their payment this can cause a risk to the organization. We must recognize what percentage each insurance company includes in the account receivables and what needs to be increased by doing the following:

  1. The hospital or clinic needs to update their web page with the list of insurance they take and increase.
  2. Have the office clerk make sure the webpage includes that the physician is listed as in the network and updated often.
  3. Seek out consultations from other specialty providers and make sure they know the insurance you take.

If the hospital wants to decrease a specific population they should try:

1. Place a cap on the amount of low income patients you can accept and have other partners to the same.

2. Reevaluate the hospital contract to see if the pay per visit can be adjusted and if it can’t stop taking low-paying payer and replace with a higher paying payer maximize your revenue.

3. To cut a specific insurance don’t market to doctors who will normally send you these patients, spending your time on marketing to higher paying patients.

4. The cost is minimal when implementing 

For the financial health of the hospital it is vitally important to keep it running smooth it is the organization discretion to decide on what they want their payer mix to look like.

Effective Decision-Making Tenets

An Article by Decision Making. (2019. Para 1-35). Suggested that the principles of management is the ability to make decisions and how it can be affected by rational judgement or non-rational aspects to include decision maker personality, peer pressure, the state of the hospital. There are eight decision making practices that administrators focus on.

  1. Examine what needs to be done.
  2. See what is in the best interest of the hospital.
  3. Create an action plan
  4. Take accountability for decisions
  5. Provide transparency
  6.  Center on opportunities as opposed to problems
  7. Have meeting that are of use to the hospital
  8. Include the team, there is no I in team.

When a problem arise it is the manager responsibility to find the root cause of the problem during the decision making process.  When a problem is not addressed correctly the administrator can miss out on what course of action to take. Changes can be improved by the manager asking the right questions and by considering the consequences of their decision making choices. They can create options by brainstorming and focus on the choices that should address.

In some cases managers have to make quick decisions without having all the facts and not knowing the for sure the consequences of their decisions. Uncertainty can rise the potential outcomes and the consequences must be well thought out. It important for the manager to pinpoint the uncertainties, the potential outcomes and the consequences of the outcomes. Mangers can explain the problem by listing what could have happened and assign possibilities to each separate possible outcome.

Most hospitals focus on decision based on principles which involves ethics or moral decisions. Ethical decision underscores the process of making decisions with the result being secondary. There is a two-step process the first one is to choice and communicate the correct principles to adhere to and secondly the manager is required to apply the correct principles. Principled decision making is used as a substitute in analytical decisions such as the hospital mission, objectives, strategies, and codes of conduct. 

Hospital also focus on the use of the internet databases to help make decisions by collecting raw data. Strategic decisions can affect the hospital and involves many decisions to include new equipment/supplies, market, purchases, mergers, other companies, joint ventures and often ran by the hospital administrator.

When approaching and making better decisions:

  1. Focus on the correct decision problem and never make assumptions.
  2.  Identify your goals and what the hospital is trying to accomplish.
  3.  Find different ways to make decisions 
  4.  Recognize the consequences
  5.  Choose the possibilities
  6. Make your uncertainties clear
  7. Think about the risk involved

Conclusion

Providers must understand the when it is suitable to use code 99214 for a routine visit by identifying moderate-complexity medical decision making in everyday practice, because of the decrease reimbursement and increase overhead cost using the correct code can increase the hospital or clinic revenue. Health care professional should always consider the medical decision making to include if the services was necessary and checking to see if your documentation consist with the code.

REFERENCES

APPENDIX

fee schedules from online

HCPCS CODE

MODIFIER

PROC STAT

MAC LOCALITY

NON-FACILITY PRICE

FACILITY PRICE

NON-FACILITY LIMITING CHARGE

FACILITY LIMITING CHARGE

CONV FACT

NA FLAG FOR TRANS NON-FAC PE RVU

NA FLG FOR FULLY IMP NON-FAC PE RVU

NA FLAG FOR TRANS FACILITY PE RVU

NA FLAG FOR FULLY IMP FAC PE RVU

NOT USED FOR MEDICARE

OPPS NON-FACILITY PAYMENT AMOUNT1

OPPS FACILITY PAYMENT AMOUNT1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

99214

A

0000000

$109.44

$79.92

$119.56

$87.31

35.9996

NA

NA

Physician Fee Schedule – for state Georgia

Tuesday, February 19, 2019 4:07:38 AM
 

HCPCS CODE

MAC LOCALITY

GPCI WORK

GPCI PE

GPCI MP

1021201

1.000

0.997

1.088

CMS.GOV. (2019).

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