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KaylaRieken

True Blue
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Waukee, IA
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Patient has elevated PSA (chronic stable) and also has a family history of prosate cancer. We are seeing him back in 6 months with repeat PSA. Is this a 99212 or can it somehow be a 99213 because of the family history of prostate cancer?
 
I would say no unless the physician's documentation meets requirements from Chart B or Risk from Chart C for 99213. Labs fall under minimal risk of patient management.
 
Hi KaylaRieken,
Based on the info provided and the assumption this is for an office visit. I would consider the chronic stable elevated PSA to be a stable chronic illness, which is a low level of number/complexity of problems. Ordering of the repeat PSA would be a minimal level of data. With no further treatment and just keeping an eye on it, I would consider to be a minimal risk. With low #/complex probs, minimal data, and minimal risk, I would consider this to be a level 2.
Laura
 
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