Wiki E/M level


Spokane, WA
Best answers
Our surgeon wants a 99205/99215 for these visits. We cannot seem to find the documentation supporting these levels. Wondering if maybe we are missing something? We are also asking so we can have information from somewhere besides us (coders) to support our decision when trying to educate the provider(s). Thank you
Note The provider already received credit for ordering of scans and labs reviewed
Are your doctors CPC certified? Have they passed the test? Have your doctors studied the 2021 E/M guidelines? Can they accurately choose an E/M based on those guidelines? At first glance it appears that you are selling yourself short.
Well, if he spent 60 minutes on the date of service on the new patient or 40 minutes with the established patient, he can have his 99205/99215.
Any thoughts on which level you would choose for the 99205 visit would be greatly appreciated. Please note provider did not document time. Provider response to query for 99215 to 99214 was yes go ahead and change. Response to 99205 to 99204 is:

Presenting problem is not a 99203. It is complicated. He has 2 surgical disease processes (Appendicitis and gallstones) complicated by prolonged hospitalization with respiratory failure secondary to Covid. Also complicated by his traumatic brain injury with history being taken through his mother.
Risk could also be a 99205. Discussed the risk of both surgical procedures as well as the risks of observation. Also talked about the risk of intubation after his prolonged hospitalization for respiratory failure

My work up:

You selected 99205

When working this up I get 99203

Presenting problem is acute uncomplicated illness (low) 99203 (documentation specifically states history of appendicitis and asymptomatic gallstones) - DX selected by provider is K35.80 Unspecified acute appendicitis
Cholecystitis is the sudden inflammation of your gallbladder. If this condition persists over time, such as for months, with repeated attacks, or if there are recurrent problems with gallbladder function, it’s known as chronic cholecystitis.

Data is 2 reviewed (CT/Hospital report) NO other tests reviewed or ordered (L) 99203
Risk is (moderate) 99204 -surgery/risk discussed (Could be a 99205 due to patients risk due to traumatic brain injury?)

Thank you
For your first example, I would code 99204. Even if you were to level risk at 5 due to patient risk factors, you would also need to get a level 5 for either number/complexity of problems or data.
Let's first look at data (this is to me the most black & white of the elements). To meet extensive, besides the 3 of category 1, you need to have either Category 2 independent interpretation of tests or Category 3 discussion with external physician/health care professional. Unless your physician not just read the CT report, but reviewed the images and independently interpreted (which is clearly not documented), you don't have Category 2. Same for Category 3 - no documentation of discussion with external health care professional.
You have: review of CT report, review of hospital records, independent historian. I will note the documentation of independent historian could be clearer, but I follow the dots. Three requirements of Category 1. So level 4 data.
Number/complexity of problems. To meet high, you must have either 1 or more chronic illness with severe exacerbation, progression or side effects OR 1 acute or chronic illness or injury that poses a threat to life or bodily function. Without active appendicitis, and asymptomatic gallstones, I don't see level 5. Multiple acute illnesses (even with complication) does not get you to level 5. At this point, whether you count number/complexity of problems as a 3 or 4 is a moot point. It's not 5.

Problems: level 3 or 4
Data: level 4
Risk: level 4 or 5
Whether each of those "OR" in problems and risk go either way, it doesn't matter. You could spend another 15 minutes trying to decide either way and it would simply not make any difference in your final level selection. You are at level 4.