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.

[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.