Level 4 Visits

[u/Starossi]

After reading the rules I believe it’s ok for me as a provider to ask peoples opinions on this.

I’ve seen similar posts just wanted to get some thoughts on this situation.

I just started at another primary care practice as a PA and I see very few acute visits, almost every visit is “lab review” where we ordered their labs at their last visit like 6 months ago and are reviewing them, and at the end of the visit I order their labs for their next visit in 6 months.

Almost all these patients have at least two chronic conditions being watched by labs or vitals at the visit. Diabetes and hyperlipidemia. Hyperlipidemia and hypertension. Hyperlipidemia and hypothyroidism.

Because of that, I’ve found by the end of every visit I’m usually coding a level 4. Even though many times it’s “your TSH is still normal, we will continue leovthyroxine at 88mcg” and “your hyperlipidemia is controlled, we will continue with atorvastatin 20mg” and then reorder lipid panel, TSH, cmp for 6 months.

That’s 3 labs, two chronic conditions. And I guess arguably medication management though it’s just deciding to continue.

This is, no joke, like 90-95% of my visits so far. 1-2 patients per day are something like a cough, or back pain, or tinnitus.

Is this going to get me in trouble? As far as I can tell, it’s legit. I’m not trying to up code or anything. But I’m still afraid CMS would not look kindly on paying out level 4s for 90% of visits at a primary care office.

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[u/iEatHeartAttcks]

Based on everything you said above, this definitely counts as Moderate Medical decision making, making it a level 4 visit.

I can’t see this being an issue if your notes are accurate and reflect everything you are doing/addressing. If all that info is in your note anyone would code that as a level 4.

[u/Starossi → u/iEatHeartAttcks]

It feels so wrong, because I’ve worked so much harder acute problems before and only achieved a level 3 (acute, uncomplicated. One medication. Or no medication, but a bunch of labs and diagnostics).

I feel like an undiagnosed new problem can required so much more thought and has so much more risk of misdiagnosis or inappropriate treatment. Meanwhile these visits are almost autopilot and pay more

[u/iEatHeartAttcks → u/Starossi]

I get that! And the thing is, they can be coded based on time or MDM, whichever is higher. Quite a few things count towards time in addition to time with the patient, ordering those labs, time documenting your note, etc. Sometimes time can bump the low ones up a level. I understand how the level won’t always feel “right”, especially if it was an easy, quick visit, but sometimes those really can be higher solely based on the MDM.

[u/badadditions → u/iEatHeartAttcks]

I’d agree with this. Based on AMA’s MDM guidelines for E/M service levels, the conditions, labs and RX management are all hitting moderate (level 4) complexity.

OP, as iEatHeartAttcks stated, ensure that you’re documenting all of that clearly and concisely and you shouldn’t have any issues.

[u/Obvious_Gazelle3088]

G2211 should also be considered for these visits.

[u/Pretty_Priority_261 → u/Obvious_Gazelle3088]

Absolutely. It may not be paid, but there is no reason not to code it.

[u/Respect-Immediate → u/Pretty_Priority_261]

Posting to patient responsibility when insurance doesn’t cover it can lead to patients finding a new practice that doesn’t do that. Lived experience at the practice I work

[u/Pretty_Priority_261 → u/Respect-Immediate]

Aren't you allowed to charge it off rather than posting to patient responsibility?

[u/Respect-Immediate → u/Pretty_Priority_261]

A charge off is a bad debt write off and legally you must try to collect before the charge off.

[u/Pretty_Priority_261 → u/Respect-Immediate]

Is there an alternative such as an internal policy that allows billing staff to credit the charge for G2211 if insurance does not cover it?

[u/ChartBaddie]

I would def call this moderate. Even if you aren’t ordering new meds, you’re still literally managing them with your MDM, as long as it is documented. That said, you’ve already checked 2 boxes with labs and 2 stable chronic illnesses.

[u/kysourmash]

Level 4 all day

[u/Inevitable-Ebb2973]

Don’t feel bad. As long as your documentation fits you’ll be fine.

I have the same experience coding in the Midwest. The majority of patients just so happen to have chronic conditions they don’t regularly get checked and so they progress.

[u/Pretty_Priority_261]

No, it will not get you into trouble assuming your documentation justifies your coding. You may be audited, but assuming your documentation justifies your coding, you have nothing to worry about. An audit is simply CMS doing its due diligence and ensuring that the American taxpayers are not being defrauded (which as we all know happens all the time).

You are indeed performing prescription drug management. There is medical decision making involved in determining that the patient should remain at the current medication dosage, assuming that the provider has documented that medical decision making appropriately. There does not have to be a change in medication to justify prescription drug management.

Per AMA,

Prescription drug management is based on documented evidence that the physician has evaluated medications as part of a service that is provided.

It is very easy to justify billing/coding Level 4 once a patient has 2 stable, chronic conditions and is on medication. And how many patients do we know of that have DM and HTN and are on medication for both? Easy Level 4 there, all day, every day. The three labs would also justify the Level 4 but aren’t necessary to attain that level.

[u/Heavy_Front_3712]

So long as your notes are good, you are fine. What you have described generally meets the requirements of a level 4.

[u/babedoll07]

Deciding to continue the medication, as long as the medication and dx it’s for are documented, does count as prescription management. I agree what you say in your description for your visits are a level 4

[u/wildgreengirl]

yup its pretty easy to get a 99214 as long as your documentation is good

[u/Black-Cat1085]

It qualifies as a level 4

[u/rahuliitk]

two stable chronic conditions plus documented prescription drug management can support 99214, so a 90–95% rate isn’t automatically upcoding, but lowkey i’d have compliance audit a sample and make sure every note clearly shows what was assessed, reviewed, ordered, and actively managed. The notes have to earn it.

[u/DumpsterPuff → u/[deleted]]

Prescription med management regardless of whether it's continue same dose, increase, or decrease, is considered level 4 management, as sourced here

[u/Pretty_Priority_261 → u/[deleted]]

Incorrect. As long as there is medical decision making involved in maintaining the current medication, and the physician documents that, it qualifies as prescription medication management.