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Wiki What E/M level

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rmness

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Two Questions:
1. Where would you place this in the risk column for patient management?
2.What level would you give?

The time documented can't be used as the patient was seen in a group setting.

HPI

HPI

The primary purpose of this service is the delivery of an evidence-based, preventative service in accordance with a US Preventative Services Task Force Grade B rating recommendation to offer intensive, multi component behavioral interventions for adults with obesity.

Patient who consented to participate in a shared medical visit primarily focused on the control of obesity and comorbidities. All medications, medical history, and recent pertinent labs were reviewed.

While in the group session, he was exposed to intensive, multi component behavioral interventions and individualized goal setting as documented below. The group session was 90 minutes in length and was delivered by a physician and in conjunction with other health care professionals, including the following: health coach, nutritionist, personal trainer, and registered dietician.

A one-on-one consultation was declined by the patient during or after the shared medical appointment to address obesity and comorbidities as documented below.

Plan

Primary hypertension

Hyperlipidemia, unspecified hyperlipidemia type

HFrEF (heart failure with reduced ejection fraction)

Permanent atrial fibrillation

Status post primary angioplasty with coronary stent

Obesity (BMI 30-39.9)

Prediabetes

Hypercoagulable state due to permanent atrial fibrillation

Irritable bowel syndrome, unspecified type

Depression, recurrent (CMS-HCC)

OSA on CPAP

Generalized osteoarthritis

The patient participated in shared medical appointments. We talked about lifestyle medicine today. We talked about the different pillars of lifestyle medicine including nutrition and activity and meditation. He still battling some medical issues with regard to his breathing. He will be seeing a pulmonologist in the near future.

A 90 minute shared medical appointment included discussion and education on the following topics: behavior modification, nutrition, physical activity, resources, and supportive counseling group.

Goal for next week: To be focusing on his appetite exercise and menu planning.
 
rmness said:
Two Questions:
1. Where would you place this in the risk column for patient management?
2.What level would you give?

The time documented can't be used as the patient was seen in a group setting.

HPI

HPI

The primary purpose of this service is the delivery of an evidence-based, preventative service in accordance with a US Preventative Services Task Force Grade B rating recommendation to offer intensive, multi component behavioral interventions for adults with obesity.

Patient who consented to participate in a shared medical visit primarily focused on the control of obesity and comorbidities. All medications, medical history, and recent pertinent labs were reviewed.

While in the group session, he was exposed to intensive, multi component behavioral interventions and individualized goal setting as documented below. The group session was 90 minutes in length and was delivered by a physician and in conjunction with other health care professionals, including the following: health coach, nutritionist, personal trainer, and registered dietician.

A one-on-one consultation was declined by the patient during or after the shared medical appointment to address obesity and comorbidities as documented below.

Plan

Primary hypertension

Hyperlipidemia, unspecified hyperlipidemia type

HFrEF (heart failure with reduced ejection fraction)

Permanent atrial fibrillation

Status post primary angioplasty with coronary stent

Obesity (BMI 30-39.9)

Prediabetes

Hypercoagulable state due to permanent atrial fibrillation

Irritable bowel syndrome, unspecified type

Depression, recurrent (CMS-HCC)

OSA on CPAP

Generalized osteoarthritis

The patient participated in shared medical appointments. We talked about lifestyle medicine today. We talked about the different pillars of lifestyle medicine including nutrition and activity and meditation. He still battling some medical issues with regard to his breathing. He will be seeing a pulmonologist in the near future.

A 90 minute shared medical appointment included discussion and education on the following topics: behavior modification, nutrition, physical activity, resources, and supportive counseling group.

Goal for next week: To be focusing on his appetite exercise and menu planning.
Click to expand...


Are you trying to determine a level for an office outpatient E/M visit (99202-99205, 99212-99215) range?

IMO, the note that you posted doesn't seem to qualify for that.

In fact, it even says that the primary purpose of the visit is a "preventive behavioral intervention." The fact that they documented co-morbitidies doesn't automatically make it a medically necessary E/M office visit.

Is there more to the office visit note that you didn't share here?
 
sls314 said:
Are you trying to determine a level for an office outpatient E/M visit (99202-99205, 99212-99215) range?

IMO, the note that you posted doesn't seem to qualify for that.

In fact, it even says that the primary purpose of the visit is a "preventive behavioral intervention." The fact that they documented co-morbitidies doesn't automatically make it a medically necessary E/M office visit.

Is there more to the office visit note that you didn't share here?
Click to expand...
Yes, I would like an opinion on what the outpatient E/M (99202-99215) would be based off that documentation in addition to where the risk of pt mgmt would be on the MDM table based on the documentation. There was PFSH in the note which I did not add otherwise there was no more documentation. This is part of a shared medical appointment program here. I'm including a link Shared Medical Appointments that discuss those further in detail. Long story short, the provider is very upset with the feedback from me, so I brought the note here to help support the feedback already given.
 
rmness said:
Yes, I would like an opinion on what the outpatient E/M (99202-99215) would be based off that documentation in addition to where the risk of pt mgmt would be on the MDM table based on the documentation. There was PFSH in the note which I did not add otherwise there was no more documentation. This is part of a shared medical appointment program here. I'm including a link Shared Medical Appointments that discuss those further in detail. Long story short, the provider is very upset with the feedback from me, so I brought the note here to help support the feedback already given.
Click to expand...


Right from your own linked policy, the patient doesn't qualify for an E/M. Your note says that the patient "declined the one on one consultation."

From the link you gave:

1781888585639.png




Note that I'm not agreeing that the policy on your link is compliant. (I'd have to do more research on the service.)

However, regardless, this patient's visit doesn't even meet the criteria for the link you provided, because they declined the one on one follow up.
 
Forgot to add:

There is no "risk of patient management" because there was no patient management done.

The provider got some history, the patient participated in a group session, and the patient declined the one on one follow up for the patient's co-morbidities.

You can't figure out the level of risk of patient management, because from the documentation I've seen so far it doesn't appear that there was any additional diagnostic testing or treatment performed or ordered.
 
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