E/M Level for Pain Following Hip Replacement (Outside Global Period)

KStaten

Networker
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Charleston, West Virginia
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Hello, everyone. :)
Does anyone think this would justify a 99213 with the new guidelines or would it only meet the requirements for a 99212? (Input is greatly appreciated!)
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Chief Complaint: Hip pain extends to knee following hip replacement
HPI: Medically Appropriate
EXAM: Medically Appropriate
DX: Aftercare following hip replacement (from 4 months ago)
Data Reviewed:
In-house x-rays performed same day

COMPLETE PLAN:
"He is having pain in his hip. He has finished physical therapy. We will rest his hip. He will use a cane. We will reevaluate him in about 2 months. We he returns, we will obtain x-rays."
 

csperoni

True Blue
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Selden
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For the documentation there, I would code this 99212.
1) Problem: LEVEL 3. With the documentation, I could not consider it acute with systemic or chronic not at treatment goal. It's possible that was actually the situation, but it's not on the page.
2) Data: LEVEL 2. I don't count any data since you are billing for the xrays
3) Risk: LEVEL 2. Rest is level 2. It states PT is done. It's also possible clinician advised to take OTC aleve, tylenol, advil, etc but again, it's not on the page.
 

KStaten

Networker
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Location
Charleston, West Virginia
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For the documentation there, I would code this 99212.
1) Problem: LEVEL 3. With the documentation, I could not consider it acute with systemic or chronic not at treatment goal. It's possible that was actually the situation, but it's not on the page.
2) Data: LEVEL 2. I don't count any data since you are billing for the xrays
3) Risk: LEVEL 2. Rest is level 2. It states PT is done. It's also possible clinician advised to take OTC aleve, tylenol, advil, etc but again, it's not on the page.
That is my understanding of it, as well, Christine. While the provider may be highly intelligent and the situation may require a lot of serious evaluation, in regards to the thought process/ effort that he/she invests into the decision, we-- as coders-- have to base it upon the documentation, as it is documented. Documentation is crucial not only for correct billing/coding, but also for continuity of care for the patient-- which should be the #1 priority. Thank you for your input! :)
 
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