Wiki E&M Level

[shruthi]

Just need suggestion regarding E&M level.

Will the E&M level for new patient be 99203 or 99204, if history and examination is complete and in MDM
# of Dx - NP with add'l WP planned
Data reviewed - MRI
Risk - Lumar radiculopathy with prescription for Neurontin 100 mg

Thanks.

 

[FTessaBartels]

Moderate MDM

Your MDM is moderate, but not knowing your level of history or exam, I cannot tell you what level of new patient visit to code.

Remember, that for a new patient visit documentation must MEET or EXCEED the level required for ALL THREE ELEMENTS

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[jan34562001]

Pregnancy referral to treat STD

Should the provider that the patient was referred to, report the pregnancy status along with the STD diagnosis?

Thanks, Janice

 

[mitchellde]

absolutely, unless he documents the pregnancy is not complicated by the STD you will use an O code for the first listed code.