Wiki Does this meet a 99204?

[carriganm]

I need help coding this E/M new patient visit. We billed it as a 99204 due to the chronic condition of ADHD and the controlled substance prescribed. I am on the fence whether this meets the AMA criteria for 1 chronic illness with exacerbation, progression and/or side effects of tx OR 1 stable chronic illness. Please see the attached chart note and advise if you would agree with 99204 billing or if you believe this should be downcoded per AMA guidelines to a 99203. I would love your reasoning and/or references behind either decision. Thank you so much.

 

[ksschroeder]

The HPI does appear to indicate that the condition may not be well managed, so potentially could be considered a chronic illness with exacerbation, progression, or side effects of treatment (See current CPT E/M Guidelines and definitions within the guidelines for #/Complexity of Problems Addressed) . However, one might expect to see a change in prescription or a recommendation to ensure the 2nd dose is taken prior to 2:00pm each day and not missed, for example. It would be difficult to support a chronic worsening problem over a stable chronic illness if there is no change to the plan of care and/or no additional workup planned. If I were auditing this visit for the provider, I would probably allow it as a level 4, but would recommend clarification on whether he would like to get a better hold on managing this problem or if it is as good as it can get even though it isn't perfect.