E&M help

Skymom16

New
Messages
9
Best answers
0
E&M
Hi,
am in need of help ! I need help on what level of E & M is this for GI..

HPi-Pt is here for a follow up for symptoms ,pt has history of annal fissure and hemorrhoids he has been taking Metamucil and it’s working very well. However when he has a overnight shift he doesn’t have a bowel movement and then when he returns home he has up to 5 bowel movements in one day..
Past Hx- address in HPI
Endoscopic studies -2013
Medications -none
Family-negative
Social -alcoholic drinks
ROS-all body - no GI per HPI
Physical examination- vitals
General
Heent
Lungs-cleared
Heart-regulars
Abd- nondisntend
Rectal-skin tags

impression-
48 yrs old male with healing anal fissure . Am recommending starting to take Metamucil one teaspoon daily +2 on his overnight shifts he will follow up in 3 months
Plan -increase Metamucil one tablespoon plus one teaspoon
2.one tablespoon of Metamucil +2 before over night shifts
Follow up in 3 months..
Now the question is he thinks it’s a 99214 ! If I can get help as he would like me to tell him why this is not an 99214.. please ! Thank you!!
 
Messages
5
Best answers
0
I think it will go 99213, As there is no moderate Medical Decision Making.


As we can see
History - Comprehensive
Exam - Detailed
MDM - Low Complexity

Some people may think that History & exam is enough for 99214 as it is having 2/3 criteria for established patient.
But some physicians needs MDM as main factor for consideration in determining E&M level.

So I will code above as 99213.
 

Skymom16

New
Messages
9
Best answers
0
Thank you so much! Thats what I thought ! This physician has his history &exam for all patients as comprehensive ! But when it comes to make mdm its always low.. if you don’t mind I have another scenario if you can help me out! Thank you
 

cnramsey

Guru
Messages
209
Best answers
0
If the Dx is established to the provider and is stable or improving that is a minimal element level 99212, no data and the management of the Metamucil OTC is low 99213. You have to have two out of the three match up. That would leave you a 99212 for the MDM.
 
Top