Wiki 2021 GI MDM question

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lnbrock

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With the 2021 E/M changes what level would you code this for a new patient:

Patient has had a change in bowel habits and has a family history of Colon Cancer in grandmother. Provider orders a Colonoscopy. My provider is coding this as a 99204 and even though he is not coding this based on time he spent maybe 3-5 minutes in the room with the patient. I am having a hard time taking history and exam out of the picture and just coding based on MDM when my providers are spending less time with the patients now than before the changes in 2021 but yet coding higher now than before the changes. I struggle to bill this as a 99204. Any thoughts or words of wisdom to put my mind at ease? Thank you in advance for your time.
 
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This sounds like an undiagnosed new problem (change in bowel habits) and plan for colonoscopy which should be moderate risk. Regardless of time spent the MDM is moderate.
 
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I'm not sure how this can be moderate..

Maybe moderate on the column of problems addressed, but no data reviewed and no specific patient risks factors would be minimal on the data column and low on the risk column... seems like a 99203 to me. I'm having the same issue with several providers and hope to get some more input from others.

Thanks!
 
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