E/M code for 1 chronic illness that is stable

[melvjj]

If a patient has a DM or hypertension and they come in for their follow up visit and the illness is stable, does this qualify for a 99212 or a 99213 (if, in this scenario, the exam level meets either a 99212 or a 99213)?

 

[sweller]

I don't believe you are giving enough information here to determine the level of visit. You would need to know the level of each component of the visit. See https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
This site also has a link to the 95' and 97' documentation guidelines.

 

[danskangel313]

You will need to provide some additional information here.

Also, does the patient have DM AND HTN or DM OR HTN?

 

[melvjj]

I will clarify my question. I am trying to figure out the level of medical decision making.

This patient is an established patient with either diabetes or hypertension (not both). They come in for their follow up visit for either the HT or the DM and are stable.

I understand that I don't have to use MDM according to the coding guidelines because I only need 2 of the 3 components that include HX, Exam, and MDM)...But, in this scenario I WANT to use MDM as one of the components.

So, if for example, let say that the other 2 components (exam and HX) meet a level 99213 BUT I'm not using both of those components because I want to use MDM as one of the 2 components, does this meet a level 99212 or a level 99213 in regards to the MDM?

 

[danskangel313]

I will clarify my question. I am trying to figure out the level of medical decision making.

This patient is an established patient with either diabetes or hypertension (not both). They come in for their follow up visit for either the HT or the DM and are stable.

I understand that I don't have to use MDM according to the coding guidelines because I only need 2 of the 3 components that include HX, Exam, and MDM)...But, in this scenario I WANT to use MDM as one of the components.

So, if for example, let say that the other 2 components (exam and HX) meet a level 99213 BUT I'm not using both of those components because I want to use MDM as one of the 2 components, does this meet a level 99212 or a level 99213 in regards to the MDM?

There's a lot of information missing that would be relevant to give you a solid answer. Are you using the 1995 or 1997 guidelines? Generally speaking, and without documentation, if the patient has one chronic condition that is controlled and nothing is done during the encounter except a quick exam and discussion, then there's no way to get it above a straight-forward level. I'd even go as far as to question whether the exam and HX levels would meet a 99213.

You'd really need to provide more information and let us know if you're using the 1995 or 1997 guidelines in order to better answer your question.

 

[thomas7331]

I agree, it's not possible to make a blanket statement about the MDM level based on just this - you have to look at the full picture of what's in the documentation. Remember too that amount of data reviewed also plays a role. Under the audit tools that use the points system, a single stable chronic problem with minimal or no data would be counted as SF MDM, but these are meant to be guidelines, not hard and fast rules.

I also recommend avoiding the use of MDM as one of the two required elements for established patient visit levels, especially at the lower level visits. I worked for a facility that followed this practice and I came to feel that this can lead to errors and underrepresent physician work. A chronic and complex disease such as DM may support significant history, exam and physician time even if the MDM comes out as SF in the audit tool. That said, if the patient has well-controlled and asymptomatic diabetes with no comorbidities (which would be rare) and all the documentation shows is that provider is looking over the labs and saying come back in 6 months, then 99212 might be appropriate.

 

[melvjj]

Thank you

Thank you for all of your input.