Can a Podiatrist bill a Level 5 E/M visit?

Can a podiatrist bill a Level 5 E/M visit? At face value, the answer would be an affirmative one. However, in reality, it would be extremely difficult to do so. Certain requirements must be met and they are not ordinary issues that we encounter on a regular, daily basis.

Let’s start with the basics. Due to the complexity that is involved with selecting a Level 5 E/M service, using Total Time to justify the level of E/M service should not be an option when it comes to Level 5 E/M services.

The Level of Medical Decision Making Table is to be used as a guide to assist in selecting the level of Medical Decision Making for reporting an E/M service code. The table includes the four levels of Medical Decision Making (ie, straightforward, low, moderate, high) and the three elements of medical decision making (ie, number and complexity of problems addressed, amount and/or complexity of data reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management). To qualify for a particular level of medical decision making, two of the three elements for that level of medical decision making must be met or exceeded.

For a Level 5 E/M service, a High level of Medical Decision Making is needed. As mentioned above, two out of the three elements that qualify for a level of Medical Decision Making must be met or exceeded.

The first element is “number and complexity of problems addressed.” For a High level of Medical Decision Making, here are the issues that qualify:

1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, or

1 acute or chronic illness or injury that poses a threat to life or bodily function.

The second element is amount and/or complexity of data reviewed and analyzed. For a High level of Medical Decision Making, here are the issues that qualify:

Extensive (must meet the requirements of at least 2 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

               Any combination of 3 from the following:

                              Review of prior external note(s) from each unique source

                              Review of the results of each unique test

                              Ordering of each unique test

                              Assessment requiring an independent historian(s)

Category 2: Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported)

Category 3: Discussion of management or test interpretation

               Discussion of management or test interpretation with external physician/other qualified healthcare professional/appropriate source not separately reported

The third element is risk of complications and/or morbidity or mortality of patient management. For a High level of Medical Decision Making, here are the issues that qualify:

               Drug therapy requiring extensive monitoring for toxity

               Decision regarding elective surgery with identified procedure or patient risk factors

               Decision regarding emergency major surgery

               Decision regarding hospitalization

               Decision not to resuscitate or to de-escalate care due to poor prognosis.

It is also important to understand the definitions of the terms that appear in the Level of Medical Decision Making Table

•                • Minimal problem: A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281).
•                • Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status
•                • Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). "Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
•                • Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.
•                • Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.
•                • Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.
•                • Chronic illness with exacerbation, progression, or side effects of treatment: A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.
•                • Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
•                • Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system.
•                • Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.
•                •​​​​​​​ Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
•                •​​​​​​​ Acute or chronic illness or injury that poses a threat to life or bodily function: An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Some symptoms may represent a condition that is significantly probable and poses a potential threat to life or bodily function. These may be included in this category when the evaluation and treatment are consistent with this degree of potential severity.
•                •​​​​​​​ Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. An example may be monitoring for cytopenia in the use of an antineoplastic agent between dose cycles. Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold
•                •​​​​​​​ Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.
•                •​​​​​​​ Social determinants of health: Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.
•                •​​​​​​​ Surgery (minor or major, elective, emergency, procedure or patient risk):
•                •​​​​​​​ Surgery—Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.
•                •​​​​​​​ Surgery—Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.
•                •​​​​​​​ Surgery—Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.
•                •​​​​​​​ External physician or other qualified health care professional: An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty. This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.
•                •​​​​​​​ Independent historian(s): An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. It does not include translation services. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.
•                •​​​​​​​ Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

As I stated right at the beginning, a podiatrist can bill a Level 5 E/M service, but as you can now see, it is not an easy task, nor is it a Level of E/M service that can be billed very often. It is indeed a rare occurrence.

This is my lengthy opinion.

Michael G. Warshaw

DPM, CPC

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