Overcoming Your “Level 5” Fears
June 19, 2023
I have found that there are two types of physicians:
- Those who shy away from using the 99205/99215 codes—”the dreaded Level 5”—for fear of triggering audits; and
- Those who use these codes as often as possible.
WHICH ONE ARE YOU?
In my years of experience, more physicians “down-code” to 99204/99214, even if their dictation clearly states and warrants Level 5. When I ask them, “Why?” I usually receive one of these three responses:
- They have been cautioned about using Level 5 too often; or
- They were audited for lack of documented information; or
- They have never used Level 5 for fear of being audited.
Here’s the good news:l
These codes are NOT as scary as people tend to think, and if used correctly the “audit police” will not show up at your door. In fact, these codes should be used more often (with the proper documentation or time, of course; as I have written in previous issues of Coffee & Coding, if it is not documented it was not done).
So, let’s clear up the myths and take the fear out of the dreaded Level 5 codes (99205/99215).
The 99205/99215 codes are for office or other outpatient visits to evaluate and manage an established or new patient. The visit requires a medically appropriate history and/or examination and a high level of medical decision-making. At least two of three key components must be present in the medical record: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. The visit must last between 40-54 minutes for established patients and 60-74 minutes for new patients.
Now let’s turn to what you will need for diagnoses to properly qualify for Level 5. I have listed a few examples (not an all-inclusive list) below:
I have listed a few examples (not an all-inclusive list) below:
- I50.9 – Heart failure, unspecified
- I50.23 – Acute on chronic systolic heart failure
- I50.33 – Acute on chronic diastolic heart failure
- I50.43 – Acute on chronic combined systolic and diastolic heart failure
- E11.65 – Type 2 diabetes mellitus with hyperglycemia
- E11.69 – Type 2 diabetes mellitus with other specified complication
- Cancer – Progression during cancer treatment; Proctitis during radiation treatment for prostate cancer1
- Hypertension – Hypertension or high cholesterol that required medication changes
- Diabetes – Diabetic ketoacidosis3
- Heart disease – Acute on chronic systolic heart failure; Acute on chronic diastolic heart failure; Acute on chronic combined systolic and diastolic heart failure2
- Asthma – Severe asthma exacerbation
Feeling a little less dread? Hopefully, you will feel even better after you read next week’s Coffee & Coding, where we will cover how to handle Complexity of Data and Risk requirements for Level 5.
CPC, CFPC, CEMC
Senior Manager, Regulatory and Coding Compliance