Short Dr. Visit – Is this Cheating?
I go to see the Physician, wait in the waiting room for quite a long time. Dr. comes in and does not sit down and stood at the door with his hand on doorknob as if he was getting ready to open the door and leave, making it a short visit. I made it a point to not stand and tried to have a discussion. After a few minutes I stand which signaled to him that the session was over and he open the door and left.
This doctor charged Medicare $450 for the session, which was a typical example of a short visit with a high charge. He turned in code 99214 Office/Patient Visit Est. Level 4, showcasing how a short visit can have a high charge.
Would this be considered Fraud? Feel free to leave your response via the comment section.
Determining whether a physician’s billing of CPT code 99214 (Office or Other Outpatient Visit for an Established Patient, Level 4) constitutes Medicare fraud depends on whether the documentation and services provided meet the specific requirements for that code, as defined by the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS). Let’s break this down based on the scenario you described and the requirements for billing code 99214.
Requirements for CPT Code 99214
CPT code 99214 is used for an established patient office visit that requires at least two of the following three components:
Detailed History: A detailed history of the present illness (HPI) with four or more elements (e.g., location, severity, duration, modifying factors), a review of 2–9 organ systems, and at least one element of past, family, or social history.
Detailed Examination: A detailed physical exam covering 5–7 organ systems or body areas, including vital signs and specific findings relevant to the patient’s condition.
Moderate-Complexity Medical Decision Making (MDM): This involves:
Addressing multiple diagnoses or management options (e.g., 3+ chronic conditions or a new problem requiring prescription management).
Reviewing or ordering moderate amounts of data (e.g., labs, imaging, or old records).
Moderate risk, such as managing a progressing illness, prescribing medications, or addressing conditions with potential for morbidity if untreated.
Alternatively, the visit can be billed based on time if more than 50% of the face-to-face time (typically 30–39 minutes total, with at least 15 minutes spent on counseling or coordination of care) is spent on counseling or coordinating care, and this is clearly documented.
The physician must provide medically necessary services for the patient’s condition, and the documentation in the medical record must support the level of service billed.
Analysis of Your Scenario
Based on your description, the physician spent only a “few minutes” with you, stood at the door, and appeared ready to leave, which suggests a brief and possibly rushed encounter. Here’s how this aligns (or doesn’t) with the requirements for 99214:
Time-Based Billing:
A 99214 visit typically requires 30–39 minutes total, with over half spent on counseling or coordination of care if billed based on time. A “few minutes” is unlikely to meet this threshold.
Even if the physician documented extensive counseling, the brief duration you described would make it difficult to justify time-based billing for 99214. CMS requires clear documentation of the time spent and the nature of the counseling.
History, Exam, and MDM:
For a 99214 based on the three components (history, exam, MDM), the physician must document a detailed history and/or exam and moderate-complexity MDM. A brief encounter where the physician stood at the door and did not engage deeply suggests that a detailed history or exam may not have been performed.
Moderate MDM requires managing a progressing illness, multiple chronic conditions, or a new problem with prescription management or moderate risk. If the discussion was minimal and no significant medical decisions were made (e.g., no new prescriptions, tests ordered, or treatment plans adjusted), the MDM may not qualify as moderate complexity.
Without access to the medical record, it’s unclear whether the physician documented enough to support 99214, but a rushed encounter raises doubts about whether these criteria were met.
Medical Necessity:
CMS requires that only medically necessary services for the patient’s condition be billed. If the visit addressed a minor issue or no significant medical issue at all, billing a level 4 visit could be inappropriate, even if documentation exists.
Documentation:
The physician’s medical record must justify the 99214 code with detailed notes on history, exam, MDM, or time spent. If the documentation does not match the brief encounter you described (e.g., exaggerating the time spent or complexity of the visit), this could be considered improper coding or upcoding.
Thanks for your input