Are you losing money with Medicare reimbursement?

Let me illustrate. Most likely, when you are reporting an initial hospital admission you are seeing a patient who is either moderate or high complexity MDM (medical decision making). Both moderate and high MDM require a comprehensive history and a comprehensive exam. In many of the inpatient admissions I audit, I see providers documenting all the necessary history and exam elements except for the family history. Missing this one simple element downgrades the history from comprehensive to detailed.  If you have a coder checking your levels, he or she is probably catching this and changing the code to 99221. If so, you are losing money each time you document this way. If not, you are probably overbilling Medicare each time.  Neither of these options are good.

I have included the 2020 Medicare National Fees below to compare the Medicare reimbursement for these three codes below:

CPT CODE	HISTORY	EXAM	DECISION MAKING LEVEL	MEDICARE NATIONAL FEE
99221	DETAILED	DETAILED	LOW	$103.94
99222	COMP	COMP	MODERATE	$140.39
99223	COMP	COMP	HIGH	$206.07

Notice that If you are admitting a high MDM patient, there is a difference of $102.13 from 99223 to 99221!  If you have to be down-coded from 99223 to 99221 only once a month that is a potential loss of $1,225.56 a year. What if you are doing this once a week? That is a potential loss of $5,310.76 a year.  

CPT CODE	HISTORY	EXAM	DECISION MAKING LEVEL	MEDICARE NATIONAL FEE
99221	DETAILED	DETAILED	LOW	$103.94
99223	COMP	COMP	HIGH	$206.07
			Loss	$102.13
			once a month	$1,225.56
			once a week	$5,310.76

Remember I mentioned that the moderate MDM code 99222 also requires a family history? If you are also making this mistake with your moderate MDM admissions as well you are losing $36.45 each time.  That is a $437.40 loss if you only do it about once a month and $1895.40 if you are doing it once a week.

CPT CODE	HISTORY	EXAM	DECISION MAKING LEVEL	MEDICARE NATIONAL FEE
99221	DETAILED	DETAILED	LOW	$103.94
99222	COMP	COMP	MODERATE	$140.39
			Loss	$36.45
			once a month	$437.40
			once a week	$1,895.40

The good news is that this is an easy fix. Get in the habit of performing and documenting a family history on when admitting a patient with moderate to high MDM. For example, if you are admitting a patient for chest pain, review the family history of cardiac disease. Then document something as simple as this “father with CAD, no other family hx of CV disease”.  Or you can review and refer to another provider’s family history. For example, reviewed Dr. Smith’s family hx from earlier today with patient no changes noted.” If the patient is unable to give a history, you simply document something like this, “unable to obtain HPI, ROS, PFSH due to severe dementia and no other source of history available.” Avoid using the phrases “family history non-contributory”, “family history negative”, and “family history unremarkable” as Medicare has already deemed these statements are not acceptable.

As you can see it only takes a small change to make a big difference.

Angie the Coder (Angela Wood, CPC) has over 25 years of experience in physician compliance, education and reimbursement optimization.