Isotretinoin follow-up visits: May I bill 99214?

The new guidelines that regulate physicians who prescribe isotretinoin for their patients are demanding and time-consuming.

Signing on with the iPLEDGE program and meeting all the requirements make some providers question whether they want to continue to prescribe the medication in their offices. The risk is high and the reimbursement is low.

Beginning Dec. 31, 2005, patients, doctors and manufacturers must register with the iPLEDGE program. Patients will receive a code number which the physician uses to dispense the medication. Patients must agree to schedule monthly doctor visits for refills and not to share medications with any other individuals.

The baseline profile the physician must obtain is comprehensive, as are the follow-up monthly visits. Physicians have been questioning whether they can justify the billing of an evaluation and management visit using CPT code 99214 in spite of the fact that they would only be examining one to three areas on the average (e.g., face, chest and back).

Criteria

In this article, I will review the criteria for a CPT code 99214 and see how those criteria could fit with a level four established office visit.

Keep in mind that whatever visit is charged, the service must always be medically necessary and properly documented. There is no recipe that allows a provider to always bill the same level of care just because the patient has a certain diagnosis.

Documentation criteria for CPT code 99214

There are three criteria that are required for a level four established office visit. They are:

For an established E/M visit, only two of the three must be met (in any combination). This means you could justify the visit by billing the history and exam only, history and medical decision-making only, or exam and medical decision-making only.

Since with the average acne patient it is virtually impossible to justify a detailed exam or 12 body areas, most likely the criteria that will be met to justify the use of CPT code 99214 would be the history and the medical decision-making. Because of the nature of the drug and the new requirements, the detailed history requirements as well as medical decision-making of moderate complexity would be consistent with the documentation and medical necessity.

History components

1.4 + HPI factors (History of Present Illness)

The most common HPI factors in dermatology include location, duration, signs and symptoms and severity.

2.2 to 9 ROS (Review of Systems)

3.1 PFSH (Past Family or Social History).

Examination components

Twelve body areas must be examined, or the examination must be detailed.

Medical decision-making

a. One or more chronic illnesses with mild exacerbation, progression or side effects of treatment
or b. Two or more stable chronic illnesses or

c. Undiagnosed new problem with uncertain prognosis

a. Minor surgery with identified risk

b. Elective major surgery with no identified risk

c. Prescription drug management.

Isotretinoin FU visit - 99214

In this section we'll look at a sample visit that would reflect a realistic established visit for a patient who is being followed for isotretinoin treatment.