“Based on your experience with the new E/M guidelines, is it possible and appropriate for a podiatrist to bill a level 4 or 5 if the documentation is supported? These higher levels have always been taboo (especially level 5). Some patients are at a higher risk with diabetes, chronic non-healing ulcers and wounds etc. Some patients need amputations. Based on the documentation, I believe achieving these higher levels is possible.”
Things have certainly changed with respect to E/M services. Until 2021, a podiatrist could not bill higher than E/M code 99203 for an initial patient. There were three key components that constituted an E/M service, the history, the examination and medical decision making. All three of these key components needed to be documented at the appropriate level in order to bill for the E/M service. Podiatrists could not justify billing for an E/M 99204 which required a comprehensive examination. The level of examination selected was not based upon the number of organ systems that you examined, but the number of organ systems that you were licensed to examine and treat. A comprehensive examination required 9 organ systems. A podiatrist by virtue of the limited scope license can only examine and treat 5 organ systems. Therefore, a podiatrist could not bill higher than E/M 99203. With respect to an established patient, podiatrists have had the ability to bill E/M 99214, but certainly not on a regular basis.
Yes, a podiatrist, based upon the 2021 E/M guidelines can now have the ability to not only bill E/M 99204/99214, but also E/M 99205/99215. The E/M codes now require a medically appropriate history and/or examination and additionally there is a time element or medical decision making. For the purpose of the above post, I am going to concentrate on medical decision making. I think that it is imperative to download a copy of The Level of Medical Decision Making table which can be used as a guide to assist in selecting the level of medical decision making for reporting an office or other outpatient 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. Please download and use the table. It is an invaluable source of information.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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