Wiki 99212 vs. 99213

[Brenda1973]

Diagnosis such as cough or nausea are 99212 self-limiting. My question is if over the counter medication is part of the plan to treat the dx of cough or nausea does that bump the MDM up to 99213? My understanding is that if medication (OTC or Rx.) is discussed in the assessment/plan than the cough or nausea is no longer considered "self limiting." Is this correct?

 

[JDACPC]

Diagnosis such as cough or nausea are 99212 self-limiting. My question is if over the counter medication is part of the plan to treat the dx of cough or nausea does that bump the MDM up to 99213? My understanding is that if medication (OTC or Rx.) is discussed in the assessment/plan than the cough or nausea is no longer considered "self limiting." Is this correct?

The OTC/Rx doesn't necessarily change the "self limited" but could change the level of service based on problem addressed, data, and risk. In your scenario, you have the Straightforward problem (self limited), Straightforward data (none), and Low Risk (for the OTC) = 99212. Rx meds are moderate risk so then you have to ask if the documentation supports perhaps an acute, uncomplicated illness instead, but have to look at the whole picture.

 

[csperoni]

I have an issue with stating any specific diagnosis is always a specific level of complexity. Let's use your example of vomiting.
Patient 1 - 14 y/o presenting with mother who vomited once yesterday after watching a disgusting video his friend showed him. No vomiting since, no nausea. Keeping down fluids and light foods. Doc advises to continue light foods for next 24 hours, then resume regular diet. And to stop watching disgusting videos.
Patient 2 - 75 y/o who vomited 7 times over the last 8 hours and unable to keep down any fluids. No nausea. No data/testing ordered or reviewed. Doc advises to proceed to ER for IV fluids and further evaluation. States "concerned about potential dehydration" but does not diagnose dehydration.
Both patients would have a diagnosis of vomiting R11.10, but not the same level of problem.

Don't forget "A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness." So a cough for weeks, and requiring OTC or Rx is likely a more complex problem than straightforward.

For any problem, you have to take the problem as it stands today. Certainly, cough or vomiting may be self-limiting 90% of the time, but could be an acute uncomplicated, acute with systemic, or even possibly an acute that poses a threat to life (but you would expect to have additional diagnoses at that point).
You must level each visit based on the documentation for that visit.

 

[jkyles]

I would just add that the Drs Levy and Hollman have repeatedly communicated that it really does just depend with meds. For example they've said that OTC meds can be low, moderate or even high risk depending on the patient. An example being aspirin form someone on anti-coagulants.

 

[Gator]

I agree with the comments here. The OTC/Rx doesn't change the "self limited". It really doesn't have anything at all to do with medication. We're combining 2 different categories here. Medication management/OTC drugs are risk and not complexity of the problem. (as JDACPC illustrated)
What would change self limited (could resolve w/o medical intervention or w/OTC meds) to acute uncomplicated is if the illness/condition is not improving or healing in a predictable way, following a typical timeline or pattern that is expected for that particular illness; essentially, it is not getting better as it should, and the progression for the illness is not following a standard course of recovery (I believe this to be the key point). So lets say cough or nausea on average is typically expected to be better within a week, but after a week, their symptoms still aren't resolved or not improving that could bump it up to acute uncomplicated.
An auditor once told me that a lot of the time when a patient presents to your clinic with a self limited "call mom" problem it's going to be an acute uncomplicated because the issue has not resolved as the patient thought it would. If the OTC cough medicine and anti nausea meds had done the job they wouldn't go see a doctor in the 1st place. Or a cut on your finger - straightforward - for which most likely one would not seek medical attention. But, a week later it's red, inflamed & warm to touch - no longer straightforward "call mom" problem. Off to the doctor you go.

 

[amyjph]

I agree with all of the responses here. You cannot just consistently connect a level of service with a complaint/diagnosis or with a management option (Rx, OTC) without taking the documentation/whole visit into account. I have audited thousands of records where cough and/or nausea are the chief complaint and they can vary widely as far as level once they are audited. Could you possibly assume many simple complaints of a cough are self-limited or minor? Maybe. However, what if the patient is a child, comes in with mom who gives the history, also has asthma, they do 3 labs, chest XR, and give prescription cough meds? That would push it to moderate if coding by MDM.
Contrast that with an adult, complains of a dry cough only for a day or two, no labs, nothing else wrong, no other health problems, they tell them to hydrate, use throat lozenges, and try OTC cough syrup at night (they just moved from a humid to a dry climate area)? That's probably a 2 if coding by MDM.

We have to look at the whole picture.