99212 VS 99213

cnramsey

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Please read office note below. Provider is picking 99213. But I'm getting a 99212. MDM is 1 established problem 1 point 99212, risk one chronic stable low 99213, data Drug screening order 99212. Two out of three gives me a 99212.
Primary Care Provider:
Accompanied by: Self
Visit Type: Follow-up

Chief Complaint: Med check

History of Present Illness:
Patient is a XX Years Old X here today for medication check. On narcotics for chronic pain. States is doing well with no concerns. No recent injury or other changes. Medicatoins continue working well. Compliant with tx. No further sx, questions or concerns.


Problem List Changes:
Changed problem from Body mass index (BMI) 34.0-34.9, adult (ICD-V85.34) (ICD10-Z68.34) to Body mass index (BMI) 32.0-32.9, adult (ICD10-Z68.32)
Assessed Back pain, lumbar, chronic as comment only



Review of Systems:
General: Denies fever, chills.
Musk: COMPLAINS OF JOINT PAIN, BACK PAIN.
Psychiatric: Denies anxiety, depression.


Vital Signs:
Weight: XXX lbs. (96.73 Kg.) Height: 68.25 in. (173.35 cm.) BMI: 32.24 O2 Sat: 94 On: Room air Pulse: 72 Pulse Rhythm: Regular
Blood Pressure #1: 142/84 mm Hg. Location: Lt Arm Position: sitting
Entered by: MA


Physical Exam:
General: Well developed, well groomed, in no acute distress.
Neurologic: Neurologically intact
Psych: Alert and oriented.


Assessment and Plan:
• BACK PAIN, LUMBAR, CHRONIC (ICD-724.2) (ICD10-M54.5) Comment only
Ongoing chronic pain with no new changes. Will continue current medicatoin at this time. New contract done today. See back X 6 months for med check.


Orders:
Urine Drug Screen [UDS]
Est. Level 3: Limited [CPT-99213]

Medications: refilled
 

thomas7331

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I'd agree with your assessment of the MDM, but the note overall meets the requirements for 99213. So even if you rank the MDM as minimal, you still have a 99213 based on an expanded history and exam.
 

Orthocoderpgu

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I'm going to agree with Thomas but for a different reason. With the implantation of EMR's the clinical staff use it as "stepping stones" where every box MUST be filled out rather than the "Buffet" that it was meant to be. I did an audit for an out of state orthopedic group where every patient had a "Comprehensive" history because the medical staff thought they had to fill out every box possible. So in today's world of documentation it's very common to see an over documentation of History and Exam. So if you were strictly going by the key components (and any two out of three key components) every patient would get billed 99214 or 99215 even though medical necessity does not support the code. Which is why CMS states that "Medical Necessity" should be the "over-arching" factor in choosing an E/M level. With that in mind this physician did not over document the history and exam like most physicians are these days. And I normally would not count a prescription refill as "Prescription Drug Management" on the Table of Risk, but I would in this case simply because the patient has a chronic pain condition that needs to be closely managed in a way that the patient does not get hooked on pain killers. And in this case the physician would need to consider bumping up the prescription either up or down depending on circumstances. If you went strictly by the book in this case MDM would be "straightforward" due to the diagnosis & management options and data. But if medical decision making is the overarching factor, due to the patient's medical condition, the thought process that goes into refilling pain medications, This would be "Low" overall MDM. I think 99213 is supported.
 
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cnramsey

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I'm going to agree with Thomas but for a different reason. With the implantation of EMR's the clinical staff use it as "stepping stones" where every box MUST be filled out rather than the "Buffet" that it was meant to be. I did an audit for an out of state orthopedic group where every patient had a "Comprehensive" history because the medical staff thought they had to fill out every box possible. So in today's world of documentation it's very common to see an over documentation of History and Exam. So if you were strictly going by the key components (and any two out of three key components) every patient would get billed 99214 or 99215 even though medical necessity does not support the code. Which is why CMS states that "Medical Necessity" should be the "over-arching" factor in choosing an E/M level. With that in mind this physician did not over document the history and exam like most physicians are these days. And I normally would not count a prescription refill as "Prescription Drug Management" on the Table of Risk, but I would in this case simply because the patient has a chronic pain condition that needs to be closely managed in a way that the patient does not get hooked on pain killers. And in this case the physician would need to consider bumping up the prescription either up or down depending on circumstances. If you went strictly by the book in this case MDM would be "straightforward" due to the diagnosis & management options and data. But if medical decision making is the overarching factor, due to the patient's medical condition, the thought process that goes into refilling pain medications, This would be "Low" overall MDM. I think 99213 is supported.
For the MDM could you tell me what you are getting for each box.. ie
Number of Dx/managment options: Chronic back pain established stable=1 point 99212
Data: I counted the drug screen order=1 point 99212
Table of Risk: If I count the Rx drug managment= Moderate 99214
That would give me a 99212. I'm not seeing how you got a 99213. Not saying your wrong just trying to figure out of you worked up the MDM since you need two out of three to meet or exceed.
 

Orthocoderpgu

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Re-read my reply. The answer is there.

To be honest by the way your response is written, I'm not sure you understand how to properly use an E/M audit sheet to calculate the different levels. And that's OK, neither did I when I first started.

The "Two out of three" is taken from the three key components of the office visit, not the three components of MDM.

But for the scenario that you asked about 99213 is supported.
 

csperoni

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I have to admit I'm a little confused here.
I would have to agree with Thomas, that if you use hx and exam, you have 99213.
If your employer (mine does) requires MDM to be one of the 2 elements, I get 99212.

Regarding just the MDM components, I have:
1 point for stable established problem = minimum number of dx/tx options
1 point for ordering test = minimum data
Risk could be either low whether you want to consider this a stable chronic illness or moderate for rx drug management.
I still wind up with straightforward MDM as number of diagnoses and data are minimum. I do not understand how MDM could be low, regardless of the overarching medical necessity. Risk doesn't count any more than dx and data do.

History and exam are both expanded problem focused.
 

cnramsey

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I have to admit I'm a little confused here.
I would have to agree with Thomas, that if you use hx and exam, you have 99213.
If your employer (mine does) requires MDM to be one of the 2 elements, I get 99212.

Regarding just the MDM components, I have:
1 point for stable established problem = minimum number of dx/tx options
1 point for ordering test = minimum data
Risk could be either low whether you want to consider this a stable chronic illness or moderate for rx drug management.
I still wind up with straightforward MDM as number of diagnoses and data are minimum. I do not understand how MDM could be low, regardless of the overarching medical necessity. Risk doesn't count any more than dx and data do.

History and exam are both expanded problem focused.
We also require MDM to be one of the 2 elements at our facility.
 

Orthocoderpgu

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I have to admit I'm a little confused here.
I would have to agree with Thomas, that if you use hx and exam, you have 99213.
If your employer (mine does) requires MDM to be one of the 2 elements, I get 99212.

Regarding just the MDM components, I have:
1 point for stable established problem = minimum number of dx/tx options
1 point for ordering test = minimum data
Risk could be either low whether you want to consider this a stable chronic illness or moderate for rx drug management.
I still wind up with straightforward MDM as number of diagnoses and data are minimum. I do not understand how MDM could be low, regardless of the overarching medical necessity. Risk doesn't count any more than dx and data do.

History and exam are both expanded problem focused.
Christine,

I'll admit that if you go "strictly" by the book that this would be a 99212 due to the MDM.

Thomas is correct, but the reasoning is flawed. That's because the writers of the 1995 & 1997 documentation guidelines were under the impression that a physician would not do or document anything that was not medically necessary. At least that is the impression that I get after reading the guidelines for decades. The best two out of three (History and Exam) would give you a 99213. This highlights the flaw in the guidelines. I work in orthopedics so here is an example. A patient comes in with a sprained finger. Is it "medically necessary" to perform a Comprehensive history and a Comprehensive exam? No. However with the implementation of EMR, that is happening repeatedly. Like I stated above, if you go by the book and not count MDM, just History and Exam, every patient would be billed 99214 & 99215 due to the over use of EMR systems and the medical staff thinking that they have to click every box in the computer!

Like your employer, I agree that MDM should be one of the two key components. That way you don't have a physician charging 99215 for a sprained finger which is not medically necessary. But due to EMR's leading the providers to over document, you could bill out the unsupported charges and technically be following the 1995 & 1997 guidelines.

In the scenario above had the patient come in for a yearly allergy prescription refill, I would never give it more than 99212. However, this patient has chronic back pain and is on narcotics. As you are aware, narcotics can be very addicting which leads to abuse. Before this physician refills this prescription, there is going to be a lot more thought behind it. Is the patient taking the drug as directed? Are they taking more than directed? Has the patient's pain increased? decreased? or changed? Are there any indications that the narcotic currently being used be switched to another drug?

Per CMS "Medical Necessity" is the overarching factor in choosing a code. In this situation, I don't think the physician is getting full benefit from the way MDM is calculated. Personally, I would give it to him due to the type of patient being seen and the narcotics.
 
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csperoni

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Thank you for elaborating. I agree there is certainly a lot of unnecessary overdocumentation, with copy and paste or clicking boxes, but that is not the case here.
My coding opinion is this does definitely deserve a 99213, but my employer would require a 99212.
For me, the medical necessity overarching helps alleviate overcoding due to overdocumentation within EMR. I have never used it in the reverse scenario, if the documentation does not give me the required elements even if the medical necessity is there. I have used it in the sprained finger type scenario to downcode, but never to increase the level.
 
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