Level 5 Cases

Question: I have a doc that is part of a pediatric cardiology practice and is arguing that basically all his cases are level 5's. The reasoning behind it is that he feels his risk level (table of risk) is always high because the children are coming in with a presenting problem of an "acute illness that may pose a threat to life or bodily function" (e.g., chest pain, fainting episode, f/u of patent ductus arteriosus, abnormal EKG). He is doing a lot of testing (EKG, Holter, echo, pulse ox) and is adamant that each patient is treated as if they could die from a cardiac issue, hence the high risk.

So our question is when you are determining a level in the Table of Risk, are you judging the problem after the patient has been seen and nothing came of it (chest pain, ruled out to musculoskeletal), or are you taking into account the risk involved when the patient presents (chest pain)? What is your take on this?

Answer: You are basing your risk assessment on the pre-results risk and differential, the risk of the presenting problem (and its potential) while at the same time counting the "further workup planned" bit from the back end of that same visit.

I share your concern for any provider who states that "all" his visits are "always" level 5 - that should raise some warnings - but based on the example you gave it seems reasonable that many or even most could be fives. At the end of the day, each one is an individual case and needs to be regarded that way.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the June 2011 issue of Physicians Practice.