Wiki E&M Level for Orthopaedic Est Pt

[msingh23]

What E&M Level will justify for a NEW and Est patient per info below on Orthopaedic patient.
HPI = 4 Elements
Hx = 2 Areas
ROS= 9 Systems
Exam = 5 Organ System including (MS), MS having 9 Elements with totaling 19 bullets.

Plan: Ordering of 3 X-ray:
1. AP pelvis,lateral L hip
2. Cervical Spine AP/lateral/obliqu
3.Lumbar Spine AP/lateral/obliqu
What E&M level will this be qualify for I am cross if L3 OR L4, the plan is my challenge not sure if the 3 X-ray will justiy?

Thanks
msingh23

 

[MikeEnos]

Regardless of whether you feel the Medical Decision Making was Low or Moderate, you don't qualify for a L4 new patient visit, because you don't have a comprehensive history. For an established patient, you would qualify as L4 because you have at least a detailed history and exam, so depending on the presenting problem you would be justified in calling that a 99214. That would be your call.

We can't really help you with the MDM, especially since you only included the diagnostic tests ordered. I can tell you that it doesn't matter if you order 1 X-Ray or 3 X-rays, it doesn't get credit for additional complexity. Same with labs, it doesn't matter if you order 1 lab test or 2 panels of tests, you don't get any more credit beyond the first test.

 

[msingh23]

Thanks, appreciate you touch on the credit for # of X-ray order, for I had a discussion before so now I am stronger on that view, for I am still seeing it thrown.
Thanks