Level 5, Part II; More on Modifier 33; and Double Dipping Redux

Editor's Note: This month's column addresses follow-up questions previously asked by Physicians Practice readers.

Level 5, Part II

Q: In your previous answer to my questions about carrier review of high level codes you said to make a statement regarding, "Several chronic problems which are either worsening or stable but when taken together have the effect of creating a high risk situation." You stated that levels 5 codes based on "breadth of management" needed to "feel" like a level 5 and clearly explain "why" these illnesses combined posed such a risk to patients. Is your recommendation that I actually add a statement to my assessment and/or plan area that explains why the combination of these multiple chronic illnesses poses a risk to the patient's morbidity/mortality? (From the March 2011 journal.)

A: Yes - that's it exactly. The discussion of level 5 codes leads to discussion of the "gray area" of the Medicare guidelines that do not specifically mention any number of chronic illnesses that are required to make up a level 5 visit. Remember, the first medical decision making (MDM) table counts four stable problems as "high" level MDM, but the table of risk simply talks about high risk examples at level 5 and doesn't give you a number.

We are all up against an unknown, or un-quantifiable, element in the Medicare documentation guidelines - namely that third part of the decision-making tables and the challenge of either quantifying or evoking the "sense" of high risk.

There were sample statements at the end of your e-mail:

Examples of various statements at end of Level 5 visits documenting "multiple, chronic stable illnesses":

1) As evaluated and managed above, patient has multiple significant cardiovascular risk factors that place patient at high risk for serious complications such as ischemic heart disease, heart attack, stroke, etc.

2) Due to coronary artery disease and other multiple comorbidities, patient is at higher risk for myocardial infarction (MI) and other serious cardiovascular complications.

3) Patient's diabetes mellitus and comorbid conditions place patient at high risk for serious multisystem, microvascular, and macrovascular complications such as retinopathy, nephropathy, neuropathy, coronary artery disease, etc.

4) Patient's uncontrolled HTN places patient at high risk for heart attack, stroke, or other serious complications.

These are certainly a step in the right direction. If nothing else they say "high-risk," they mention one of the more recognizable examples mentioned in the table, i.e. MI, and do convey a sense of risk.

On the last one, remember that "uncontrolled" could be further modified by "moderately" or "severely" - that there are degrees of non-control. The word severe appears in the list of examples too on the first bullet in that table of risk. Go that way if it is more of an M/M problem with one thing rather than the breadth of management and collective risk issue.

Although these examples move you in the direction of what we are looking for, and in any given chart may well do what we need them to do, I still want to caution you to amend them as needed to reflect the specific issues and gravity pertinent to that patient that day. Don't say "the patient's uncontrolled HTN ..." or "the patient's diabetes…" - say "Mr. Smith's uncontrolled HTN..." and "Mrs. Smith's diabetes..." Remember that the OIG is concerned about cloning - don't overwork these statements.

More on Modifier 33

Q: I keep hearing about the new modifier 33 but it's not in the CPT manual. Am I supposed to be using it? (From the February 2011 journal.)

A: Yes you are, but it may be difficult to determine when to use it for given payers and given services. CPT 2011 went to print long before the AMA put the modifier information on their website. In fairness, this is a response to healthcare reform and by necessity came late in the year.CPT has created a new modifier 33 - which allows providers to report to payers that a given preventive service is covered under new healthcare laws and that patient cost sharing does not apply.

The Patient Protection and Affordable Care Act made it mandatory for all healthcare insurance plans to start to cover some preventive services and immunizations as part of all benefit plans and not subject to deductibles and copays for some specified preventive services. This is called first-dollar-coverage and means that "cost sharing" - or copays and deductibles - aren't applicable to these services.

This modifier may also be used when a service began as a preventive service and was converted to a therapeutic service. The example the AMA gives is a screening colonoscopy converted to a polypectomy.

You will need to find out which plans are converting at their next renewal period to meet the new law. Then you'll need to identify which services they now cover as preventive to which modifier 33 applies. This will require some work on your end payer by payer.

Double Dipping Redux

Q: After reading your article on the history of present illness (HPI) and the chief complaint a discussion arose between the auditors in my office regarding "double dipping" and I am wondering if you would mind clarifying something for us. (From the November 2010 journal.)

One auditor says that it is permissible to obtain a review of systems (ROS) from the CC of "arm pain" - using arm as the location in the HPI and pain as the ROS under MS. I have never audited in this manner and would appreciate any advice or direction you can offer.

A: In the article you refer to I was surprised that any reviewer would have some type of "mutually exclusive" approach to elements of the HPI and CC. In your example, it looks like the CC is being used as the source of HPI and ROS elements.

To my knowledge, there is no body of regulation that really parses these issues in any way at all outside of the HPI/ROS double-dipping discussion. But in the spirit of the thing, the CC should be a concise statement, the HPI should amplify or expand on that (not rely on it), and the ROS is a discussion of potential or actual related issues related by the patient in response to a question or questions by the physician.

Any further attempt to qualify these components and their shared or discreet attributes is speculative at best. I think the example of the "arm pain" with "pain" as ROS is a huge stretch. It is simply the CC - HPI would develop the symptomology - and ROS questions would look for cause or context.

But at the end of day, it's all subjective.

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 April 2011 issue of Physicians Practice.