3 Chronic conditions and level of service

[CTENNESSEN]

If you have a patient who has 3 chronic conditions that are all stable and the provider doesn't change any meds and just refills them would this be a level 99213 or does it automatically get the provider a level 99214?

Thank you

 

[Pathos]

Good morning,

What you are describing sounds like the 1997 guidelines of the CMS E/M guidelines. Having 3 stable chronic conditions could net you an Extended History of Present Illness (HPI). Note that the HPI is just one of the three components of the History section. In order to determine the overall History, documentation must show the complexity of Review of Systems (ROS) and Past Medical/Family and Social History.

Additionally, there is the Physical Examination E/M component which should be addressed as well.

Finally, don't forget about the Medical Decision Making (MDM) either. This E/M component is often the driver of the patient visit, depending on your payer.

Here are the CMS E/M guidelines which should help guide you in the right direction.


Hope this helps!

 

[ncomer]

This is a conversation that we have often..."ticking the boxes" can get you to 99214, however is the MDM truly moderate? If the patient has 3 stable conditions, no med changes, no additional work-up needed, etc then 99213 probably would be most appropriate. Using the examples in Appendix C of the CPT can also help.