Wiki 99212?

[Gator]

I say 99212 doc says no it is higher.
Moderate number & complexity of problems. Minimal or No data = straightforward. Minimal risk for Diet, exercise & monitoring = straightforward. = 99212. As documented I advised that "off medications" and "takes antacids" etc. are just statements and no management.
Assessment
• Essential hypertension I recommended xxx continue to monitor home blood pressure readings closely. xxx is off medications
• GERD xxx currently takes antacids to help with discomfort. I recommended xxx make dietary changes
• Hyperlipidemia I recommended xxx improve dietary discretion and increase activity
Plan
• Return to the clinic if condition worsens or new symptoms arise• Follow-up visit Annual wellness in October
HPI
• Allergy list reviewed • Problem list reviewed • Medication list reviewed xxx comes in today for follow up for hypertension, hyperlipidemia and GERD. xxx blood pressure is elevated some on today's exam. xxx has gained 8 pounds over the past six months. xxx also is concerned about reflux disease. xxx has been recovering from R total knee surgery. I reviewed medications with xxx today

 

[csperoni]

If the clinician provided services higher than 99212, then they did not document well.
I agree that stating the patient takes an OTC, or no longer takes a prescription is not demonstrating they made a decision regarding the medication. They receive credit for medical decision making, and this note does not indicate that.

Here is what NGS has about prescription drug management:

1. Please define prescription drug management relative to MDM.
   Answer: In order to count prescription drug management there must be documentation of at least one of the following factors:
   1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
   2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
   3. Documentation of a decision to initiate a new prescription drug(s).
   4. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
   5. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Prescription drug management is based on the documented evidence that the provider has evaluated medications during the E/M service as it relates to the patient’s current condition. Simply listing medications that patient takes is not prescription drug management. Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications.

 

[Liz0914]

I would give the provider a 99213. 2 or more stable chronic conditions and low risk of morbidity.

 

[sls314]

I would give the provider a 99213. 2 or more stable chronic conditions and low risk of morbidity.

Out of curiosity, what are you seeing in the patient management that you're considering low risk?

The physician suggested dietary changes and an increase in activity. Those are minimal risk activities.