help on level 5

Bringing a very controversial subject to the board. I have a physician (well seasoned) that will see a patient with multiple chronic issues. There are no exacerbations to the illness, they are stable, no change in the treatment plan. He does very in depth documentation, but overall the patient has just come in for their 3 or 4 month check up. This provider continually charges a level 5, because of the amount of chronic illnesses he addresses, even though there is very seldom any change. I'm trying to explain to him that medical necessity isn't always met for a level 5 because he didn't change anything, documentation states very clearly that the patient is very stable and there are no changes to be made in the treatment plan. Am I wrong? I understand that auditing is very subjective and there is a lot of ambiguity. Any thoughts from anyone on how to explain overall medical necessity and level 5 coding? I appreciate your time and words. I'm struggling with this one.

re: help on level 5

Here is a trick I learned from a physican who is also a certified coder...If you look at the table of risk, a large amount of stable chronic illnesses only gets you to moderate...and this is where I tell my docs to start (backwards!) when considering what kind of visit would be supported my medical necessity. Depending on labs, medications, etc...I'm thinking he should be at a level 4 max.
However, depending on the exact chronic issues, even if they are stable, consider if the problems, or the medications they are on...if they require close monitoring and a comprehensive exam.

Try this

Time the doctor in the room and see if she is in there long enough to justify time-based coding. If it is 40 minutes then she can code level 5 as I am sure over 50% was counseling.

I can see a patient with DM, HTN, High Chol, OA and gout and cancer and review all issues and review vaccines and screening needs and order labs and refill meds and finish my EMR note in 12 minutes--level 4

I can see a patient with chest pain, get an EKG that shows an acute MI, get the history and ask the ROS and call 911 and be done in 4 minutes--level 5.

As LL said, it's really all about risk. We may not like it but who makes the rules?? Someone else!

Here is an article on "coding from the bottom up"

http://www.medscape.com/viewarticle/585559