99202 vs 99203

Elizabeth83

Contributor
Messages
17
Best answers
0
I would like to know others opinions on this. Any auditors out there? Thank you
99202 verses 99203.

The patient has a stable chronic illness, 1 data, and gallbladder disease symptoms discussed, with patient to follow up PRN.


HISTORY OF PRESENT ILLNESS
The patient is here for evaluation of gallstones. gentleman who states that he had a workup with an ultrasound of the abdomen because he had black stool several months ago. He has not had that episode anymore. He denies any abdominal pain. He pretty much eats whatever he wants. He does suffer from esophageal reflux and he takes famotidine with usual control of his reflux. In any case, when he had the ultrasound of the abdomen, it showed cholelithiasis, and, given these findings, he comes in for general surgical evaluation. At this point, he is not really describing any symptoms of biliary colic.
PROBLEM 1
COMPLAINT
Complaint: Evaluation for gallstones.

ABDOMEN:
Visual Inspection: The abdomen was not distended.
Auscultation: The bowel sounds were normal.
Palpation: The abdomen was soft, no abdominal guarding, abdominal non-tender + rectus diastasis, and no abdominal rebound tenderness. No mass was palpated in the abdomen.

TEST CONCLUSIONS
I reviewed the ultrasound of the abdomen and this shows cholelithiasis without evidence of cholecystitis and hepatomegaly.

ASSESSMENT
81 year old gentleman with asymptomatic gallstones.

PLAN
I did discuss with him at length the signs and symptoms of gallbladder disease and he voiced understanding. Followup prn.
 

thomas7331

True Blue
Messages
4,262
Best answers
11
This seems pretty clearly a 99203 to me - MDM is at least low, and definitely not straightforward. What is leading you to think it might be 99202?
 

Elizabeth83

Contributor
Messages
17
Best answers
0
I'm confused by reading others posts. Some say you need to see something definite stated for treatment. Others are going with what you are saying. chronic problem equals at least low risk.

To me the doctor isn't planning anything else for the patient. So is it leads me to believe that maybe an auditor would think its a 99202. Usually, we go with the 3's but i just want to know others thoughts. Make sure we do not run into issues.
 

thomas7331

True Blue
Messages
4,262
Best answers
11
I'm confused by reading others posts. Some say you need to see something definite stated for treatment. Others are going with what you are saying. chronic problem equals at least low risk.

To me the doctor isn't planning anything else for the patient. So is it leads me to believe that maybe an auditor would think its a 99202. Usually, we go with the 3's but i just want to know others thoughts. Make sure we do not run into issues.
Well, there's some truth to both sides of that. But in this case, I don't think it's correct to say the doctor 'isn't planning anything else'. The documentation reflects that the physician's decision isn't to 'do nothing', but is rather to opt not to intervene at this time but to educate the patient to recognize if the condition worsens and to return for care if and when that happens. That's a different scenario from a case where a patient comes in with a minor problem that does not require treatment and will heal on its own. In this case, the gallstones aren't likely going to resolve on their own - by the very nature of this problem, the physician (and the patient) are assuming a significant risk here by deciding to wait. In other words, due to the nature of this disease, the decision not to treat medically or surgically actually does involve risk.

I think that any auditor is going to recognize that the management of this type of problem involves more than minimal risk and would not classify this as 'straightforward' MDM. In my opinion, 99203 is perfectly appropriate (it's not a high level E/M code, so unlikely to be audited at all) and I can't imagine that an auditor would challenge you for coding it that way for a condition as complex and potentially serious as cholelithiasis.
 
Last edited:

csperoni

True Blue
Messages
1,892
Location
Selden
Best answers
3
I think most of the internal auditors in my organization would call this 99202. I however, would call it just barely 99203 (due to poor documentation). If I got dinged on an audit, I would dispute it.
I would also use this as an example to help educate my clinician. The entire outpatient MDM change in 2021 is to give the provider more credit for the knowledge in their head, and not worry about how many HPI elements or organ systems are documented. However, the physician needs to indicate on the record what is going on in their head. I totally believe that the clinician decided to not perform surgery on this patient at this time. But it's not clear on the page. Remember the risk is "decision regarding surgery" not decision to recommend surgery. So if the clinician had simply added "surgery not recommended at this time", that would be a clear cut 99203. No dispute; no difference of opinion; no ding on an audit. Six extra words and no grey area.
 

Orthocoderpgu

True Blue
Messages
1,902
Location
Salt Lake City, UT
Best answers
9
I totally agree with Christine and Thomas. Keeping in mind the age of the patient and that at least at this time it would not be medically necessary to remove the patient's gallbladder. Had the gallbladder been inflamed, surgery may have been recommended. There is a very good chance that the gallbladder will become inflamed in the future. So surgery is not off the table, not even close. Just not in the immediate future. Providers frequently document "from their viewpoint", meaning that in this situation it's clear from a physician's perspective that surgery is not an option at this time. It may be clear in their head, but as Christine has pointed out, those decisions need to be documented to give them the credit that they deserve.
 

OpenClaims

Expert
Messages
337
Location
Miami, FL
Best answers
0
I believe that this would qualify as a 99202. The MDM is actually low, because the provider is saying to "follow-up prn" or "follow up as needed." From what you've given us, there have not been any tests ran and/or prescriptions or procedures prescribed or performed. Because of the new 2021 E/M guidelines, I'd consider this a 99202 for low MDM, unless the time statement for the visit is listed otherwise.
 

csperoni

True Blue
Messages
1,892
Location
Selden
Best answers
3
I believe that this would qualify as a 99202. The MDM is actually low, because the provider is saying to "follow-up prn" or "follow up as needed." From what you've given us, there have not been any tests ran and/or prescriptions or procedures prescribed or performed. Because of the new 2021 E/M guidelines, I'd consider this a 99202 for low MDM, unless the time statement for the visit is listed otherwise.
Low MDM is 99203, not 99202. Straightforward is 99202.
 

Elizabeth83

Contributor
Messages
17
Best answers
0
Thank you all for your responses. I will talk to this doctor and use it as an educational example. I would personally feel better if he would change his plan to say that he will not be proceeding with surgery at this time and if symptoms arise to please contact our office. I will go with a 99203 if he adds an addendum.
 
Top