Does a specific DX automatically deem a higher E/M level?

Deb2009

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I am being told that if a patient has a particular dx the E/M is automatically 99223/99233? Your thoughts?
a few examples:
COPD with exacerbation (J44.1)
AMS (R41.82)
Leukocytosis (D72.829)
Dementia (F03.90)
 

CodingKing

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The patients DX is not one of the 3 key components in E&M leveling so no that cannot be used to determine the specific level. Every persons circumstances are different.
 

Deb2009

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Thank you, I agree however I am getting dings on my audits :-( I will continue to "discuss" this one with them!

Any further comments will be greatly appreciated.
 

mitchellde

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I would definitely question this. If the documentation is present the diagnosis is checked to see if they match up. CMS says the medical necessity is the overarching criteria for a visit level, however it cannot determine the visit level. You can however use the diagnosis to see if the visit level is reasonable for that given medical necessity. For instance if the patient has a skin rash with little to no skin evaluation, then it is suspect for point and click template fill in. If you have skin issues then it is expected that the evaluation will be heavy on the skin and would not includ a GI or GU exam for instance. So the question would be why did the provider consider that a necessary part of this exam or was it simply brought forward from a previous exam.
In addition you could not look at a diagnosis such as chest pain or severe migraine and very little exam and straightforward decision making and decide that the severity of the diagnosis surely warrants at least a level 3 when the documentation is a solid level 2.
 

Deb2009

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I would definitely question this. If the documentation is present the diagnosis is checked to see if they match up. CMS says the medical necessity is the overarching criteria for a visit level, however it cannot determine the visit level. You can however use the diagnosis to see if the visit level is reasonable for that given medical necessity. For instance if the patient has a skin rash with little to no skin evaluation, then it is suspect for point and click template fill in. If you have skin issues then it is expected that the evaluation will be heavy on the skin and would not includ a GI or GU exam for instance. So the question would be why did the provider consider that a necessary part of this exam or was it simply brought forward from a previous exam.
In addition you could not look at a diagnosis such as chest pain or severe migraine and very little exam and straightforward decision making and decide that the severity of the diagnosis surely warrants at least a level 3 when the documentation is a solid level 2.

Thank you, I definitely agree! I requested further explanation as to why they would mark my level incorrect and awaiting a response. In the meantime reaching out to fellow coders on this site for input.
 
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