Wiki E&M level

[RebeccaMoney]

Would someone be willing to review the attached office note and tell me what level you would give it and why? My provider is asking for 99204. Surgery was discussed but patient decided to proceed with an injection. Patient also has a family history of bone cancer. I think I agree with that but would like another person to look at.
Thank you,

 

[jhean.marca@yahoo.com]

no attachment

 

[RebeccaMoney]

Would someone be willing to review the attached office note and tell me what level you would give it and why? My provider is asking for 99204. Surgery was discussed but patient decided to proceed with an injection. Patient also has a family history of bone cancer. I think I agree with that but would like another person to look at.
Thank you,

 

[jhean.marca@yahoo.com]

per my review, I believe this should fall only to 99203, low for problem addressed-1 acute, uncomplicated illness or injury
, unless the symptoms for concern for bone cancer was addressed as that could fall to • 1 undiagnosed new problem with uncertain prognosis;
data reviewed - fall only to straightforward
risk- moderate, hope it helps, thank you

 

[natashalage]

I agree with 99203 also. Dx-1 acute uncomplicated illness, Data- 1MRI reviewed. Risk- moderate for injection.
It's not a dx w/ systemic symptoms or Undiagnosed dx or chronic w/exacerbation. For data- no interpretation, or discussion with other providers, no 3 tests reviewed. Surgery was not a priority. No work-up; just will see the pt in 3 weeks.

 

[amyjph]

Agree, not a 4.

 

[MelodyCPC]

Would someone be willing to review the attached office note and tell me what level you would give it and why? My provider is asking for 99204. Surgery was discussed but patient decided to proceed with an injection. Patient also has a family history of bone cancer. I think I agree with that but would like another person to look at.
Thank you,

I agree with 99203. During my first read through the visit note I was mentally calculating Moderate for Data Analyzed (Category 2 Independent interpretation for the MRI) he reviewed MRI images "in depth" with the patient. However, he does not state what his interpretation of those images was, so that can't be counted. Moderate data would have moved the level to 99204 for this visit. This is an opportunity for provider education for complete documentation of any independent interpretations that are performed.

 

[amyjph]

I agree with 99203. During my first read through the visit note I was mentally calculating Moderate for Data Analyzed (Category 2 Independent interpretation for the MRI) he reviewed MRI images "in depth" with the patient. However, he does not state what his interpretation of those images was, so that can't be counted. Moderate data would have moved the level to 99204 for this visit. This is an opportunity for provider education for complete documentation of any independent interpretations that are performed.

Yes, was going back and forth too but it's too vague and no interpretation specifics on the MRI/XR.

 

[csperoni]

I agree with 99203. During my first read through the visit note I was mentally calculating Moderate for Data Analyzed (Category 2 Independent interpretation for the MRI) he reviewed MRI images "in depth" with the patient. However, he does not state what his interpretation of those images was, so that can't be counted. Moderate data would have moved the level to 99204 for this visit. This is an opportunity for provider education for complete documentation of any independent interpretations that are performed.

SAME. I saw that decision regarding surgery and review of images and immediately thought - oh, this is a level 4 overall.
Honestly, I think this was likely a situation that the clinician PROVIDED a level 4 service, but only documented a level 3 service. Prime educational opportunity for moving forward!!

 

[amyjph]

This was essentially a trigger finger/tenosynovitis where they did an injection and f/u is four weeks out. If they would have documented independent interpretation of the MRI and XR performed elsewhere better, "maybe" it would be a 4, still not sold on that.
Also, in looking again there is an error where it switches from right to left finger being commented on. More feedback for provider.

 

[RebeccaMoney]

SAME. I saw that decision regarding surgery and review of images and immediately thought - oh, this is a level 4 overall.
Honestly, I think this was likely a situation that the clinician PROVIDED a level 4 service, but only documented a level 3 service. Prime educational opportunity for moving forward!!

Thanks so much for you input. I was going between 99203 and 99204.