I don't feel ortho is always black and white. I have seen plenty of justified level 5s. However, I have also seen every single visit being coded as a 5 which is suspect. It depends on the documentation. If every single visit is being coded as a 5, that would be questionable. If the documentation supports it, and using MDM, there is no reason for them not to code the correct level. There could be a case where it is possible a 5. What if this was a discussion of a possible TKA with a high-risk patient who has diabetes w/ high A1C, heart problems, maybe they had a hx of CABG, they are on Eliquis, they have some other chronic conditions. They are in severe pain with knee deformity, they are using a cane. They cannot perform or participate in their normal ADLs and activities. They need a disability parking pass because now they can't walk more than a short distance. The provider gives them a course of some type of pain medication while waiting for surgery, provider does extensive data review (maybe they brought in outside XR or MRI and PCP notes?), and they have to get a workup from the cardiologist, PCP, etc. Keeping in mind, all of this is DOCUMENTED in the note with the "thinking process" you can see in the note. That could be a 5.
Go back to the AMA E/M definitions:
https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.
Surgery (minor or major, elective, emergency, procedure or patient risk):
Surgery—Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.
Resources:
This isn't the MAC for NE, however the E/M FAQ has good info:
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
This is ED focused but also has good info:
https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs
You can check in here for E/M FAQs:
https://www.kzanow.com/coding-coaches/category/Orthopaedics
This has case examples ($ webinar):
https://educate.kzanow.com/products...-hospitalobservation-billing-and-em-modifiers
This is from 2021 but might have help:
Take a sample of the providers notes and use an audit sheet. How does that look? Talk with the provider about it. Can you see the thinking process on "paper"? Are they doing more but it is not being captured in the documentation? Ask them to explain why and help you understand. Did they connect the dots if the patient is more complicated. A lot of those in the age group for TKAs have a lot more going on and may be higher risk for major surgery. Ask your provider their definition of major/minor (not the global days).