99213?

Cheezum51

Expert
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I think it would be assuming the provider's office isn't doing the scan or billing for it.

Tom Cheezum, OD, CPC, COPC
 

KaylaRieken

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Can I ask how this makes it a 99213? In the number of problems addresses I do see the moderate 99214, but in data and risk isn't it straightforward? 99212?

Also another example I have is: Stable chronic elevated PSA and they come back in 6 months for a repeat psa. is this a 99212?
 

lcolborn

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Going back to the first scenario, 2 stable chronic illnesses, and a scan ordered. Yes, 2 stable chronic illnesses falls in Moderate Number and Complexity and only 1 test ordered under data . If you look at the MDM Grid across yo have another column, Risk of Complications/or Morbidity . Yes you did not meet it on the data but you met it on the Risk Column. You have to meet 2 out of the 3 elements . It needs to meet or exceed and it doesn't have to be in any particular order you are matching for 2.

On the stable chronic elevated PSA/PSA lab... ,if nothing else is being ordered or no other elements to consider ,I would put that on level 3 too.
I know it's kinda confusing for all us right now and there are still some gray areas. Hopefully we can all learn this new ways, and have some answers on some gray areas. By no means , I'm not an expert, so please seek other opinion as well.
 

sugarjoe

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I am also having difficulty with these new guidelines. Is the rationale for the the low risk in the above first scenario because of the additional testing (scan)?

If anyone can give me an opinion & reasons for the following scenario, I would appreciate it as well-I feel more confused now than before:

Healing fracture and we bill for the x-ray in the office. Follow up in another month. 99212? (no longer acute ? minimal risk or low risk?)
 

KaylaRieken

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I guess I am still confused because why would the risk of a bladder scan and psa be low? Wouldn't it be minimal? (ultrasound & venipuncture)
 

zcometa

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Local Chapter Officer
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In the first scenario, I say it would be a MINIMAL MDM.

Rationale:
1. 2 chronic stable meets MODERATE for Element 1: Number & Complexity of Problems addressed
2. Bladder Scan meets Minimal on Element 3: Risk (see https://www.aapc.com/codes/em-calculator-2021/mdm ultrasound is considered minimal)
3. MODERATE + MINIMAL MDM= MINIMAL, since MODERATE meets and exceeds MINIMAL but not the other way around.
4. Also, if you include the information about Element 2: Data, then you only have one (order unique test: Bladder scan) for Category 1 which would also be MINIMAL since you need at least 2 in Element 2: Category 1 to be a LOW.

So, you have a Element 1: MODERATE+ Element 2: MINIMAL+ Element 3: MINIMAL= Final MDM is MINIMAL
 
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