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Family Practice Doctors: Is It CPT 1995 or 1997 Guidance?

Right now, CMS allows physicians to pick to follow the 1995 or 1997 guidelines for determining whether an evaluation and management (“e/m”) visit qualifies for a 99214 versus a 99213. The biggest difference between the two policies is that the 1995 guideline allows you to check by systems, rather than individual organs. Starting January 1, 2023, there are a lot of revisions, including a 2021 guidance that will be used. But, for dates of service before 2021, physicians can pick between 1995 and 1997 guidance.

Why is this an issue?

If you are a family practitioner and get audited by Medicare, Medicaid, or private pay, you better be sure that your auditor audits with the right policy.

According to CPT, 99214 is indicated for an “office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity.”

Think 99214 in any of the following situations:

  • If the patient has a new complaint with a potential for significant morbidity if untreated or misdiagnosed,
  • If the patient has three or more old problems,
  • If the patient has a new problem that requires a prescription,
  • If the patient has three stable problems that require medication refills, or one stable problem and one inadequately controlled problem that requires medication refills or adjustments.

The above is simplified and shorthand, so read the 1995 and 1997 guidance carefully.

An insurance company audited a client of mine and clearly used the 1997 guidance. On the audit report, the 1997 guidance was checked as being used. In fact, according to the audit report, the auditors used BOTH the 1997 and 1995 guidance, which, logically, would make a harder, more stringent standard for a 99214 than using one policy.

Now the insurance company claims my client owes money. However, if the insurance company merely applied the 1995 guidance only, then, we believe, that he wouldn’t owe a dime. Now he has to hire me, defend himself to the insurance company, and possibly litigate if the insurance company stands its ground.

Sadly, the above story is not an anomaly. I see auditors misapply policies by using the wrong years all the time, almost daily. Always appeal. Never roll over.

Sometimes it is a smart decision to hire an independent expert to verify that the physician is right, and the auditors are wrong. If the audit is extrapolated, then it is wise to hire an expert statistician. See blog. And blog. The extrapolation rules were recently revised…well, in the last two or three years, so be sure you know the rules, as well. See blog.

Broken Promises Could Promise Disaster for Pediatricians! or “I Don’t Give a Damn” What the Law Is!

In 2013 and 2014, those of you who are primary health care physicians received a boost in Medicaid reimbursement rates up to the Medicare rates for E&M and vaccine administration CPT codes. Many of you self-attested to being primary care physicians. In other words, you determined that you act as a primary care physician. No official acting on behalf of the government reviewed your self-attestation and approved or denied your self-attestation.

What if the government decides, retroactively, that you did not qualify as a primary care physician and attempt to recoup the enhanced payments?? Is that allowed? “A retroactive take back?”

We all know that retroactive take backs occur in other types of audits!

This whole situation reminds me of my favorite movie of all time: Gone With the Wind…you know, Scarlett O’Hare, Rhett Butler, the Civil War…Over Thanksgiving, AMC had a Gone With the Wind marathon, and I must have watched it 4 times (I was sick, so I couldn’t do much else).

The plot is that Rhett is in love with Scarlett the entire movie, which spans over a fictious, “movie time” of two decades. And Scarlett is not in love with Rhett the entire movie until the very end.Once she finally realizes her love for Rhett, he is beyond frustrated and wants nothing to do with her.

She asks, “Rhett, oh, Rhett, what am I supposed to do?” To which he responds, “Frankly, my dear, I don’t give a damn!”

There are many themes found in Gone With the Wind, but the one most appropos is “You may think you understand reality, but, in the end, your reality may be a fictitious dream.”

Similarly, in 2013 and 2014, if you are a primary health care physician, you received a boost in Medicaid reimbursement rates up to the Medicare rates for E&M and vaccine administration CPT codes. You believed the rate hike to be reality.

This rate hike was a big deal for physicians, especially pediatricians. Pediatric practices rely heavily on Medicaid, usually from 20-100%. This rate hike took a reimbursement rate of approximately 78% of the Medicare rate, which, by the way, has been frozen by our legislature at the 2002 rate, plus an additional 3% reduction, followed by another 1% reduction to 100% of the Medicare rate. Quite an increase!

Well, that so blissful increase in Medicaid rates may come back to bite you!!! You thought that you were receiving higher Medicaid reimbursement rates, but, in the end, may you have to pay it back?

The reality of receiving higher Medicaid reimbursement rates may truly only have been a fictitious dream.

“Why,” you demand. “Why?” “Well,” says the government, “I don’t give a damn what the law is.”

Caveat lector: It is not 100% certain that you will be audited. This blog is only a warning as to a possibility. If, in fact, you are audited, then you have legal rights!

Let’s go over why there may be audits for those of you who self-attested to being primary care physicians…

In order to receive this increased rate hike, physicians had to self-attest that he/she :

  1. “Is Board certified as family medicine, general internal medicine, or pediatric medicine; and/or
  2. Has furnished evaluation and management services under codes described in paragraph (b) of this section that equal at least 60 percent of the Medicaid codes he or she has billed during the most recently completed CY or, for newly eligible physicians, the prior month.”

If you are Board certified in family medicine, general internal medicine, or pediatric medicine, there should not be a problem. There isn’t anything to argue. You are either Board certified or not.

However, if you are not Board certified, you will be relying on the government’s auditors to determine whether your practice comprises 60% of applicable Medicaid codes during the most recent calendar year.

Hmmmmmm…

Then, if the government’s auditors determine that your practice comprises of only 57% of applicable Medicaid codes, you may be charged with returning all the money you received as enhanced payments during 2013 and 2014.

And we all know how accurate some of our government’s auditors are…

So there you were, a physician, happy to self-attest to being a primary care provider, happy to receive higher reimbursements for two years, and with no thought of recoupments.

Then…BOOM…you are hit with the realization that you may be liable to the government for a recoupment of those enhanced reimbursements.

Because, frankly, my Dear, the government does not give a damn. Your reality was, in fact, a mere fictitious dream.