Wiki E/M Question

[sankoe@keystoneruralhealth.com]

Patient is being seen for finger pain from shutting it in a door swollen can't bend it, ankle pain and knee pain from tripping on rug in living room and rhinitis, acute. Antibiotic prescribed. Ordered x-ray of hand and x-ray of the ankle and knee. I have moderate data and moderate risk which brings this to a 99214 the doctor is coding as a 99213 as he feels its low risk for morbidity and mortality even though the criteria for the new E/M brings the visit to a 99214. Since the criteria is meet regardless of the risk for morbidity and mortality per the doctors thoughts would you code this a 99213 or a 99214?

 

[lcolborn]

I would code this as a level 4, Moderate/99214. It's meeting the 3 + data and prescription in the MDM Grid.

 

[thomas7331]

Risk is a very subjective area and I generally would defer to the provider's opinion, so I would consider this low risk if that is the provider's assessment. However, the provider should also understand that risk alone does not determine the level of the E/M service - you could still have a 99214 if the other two MDM categories meet the moderate level.

 

[kimberlywatson]

I agree with moderate for the Diagnosis/Complexity as he's treating 4 issues. Keep in mind, if the provider is billing for the xrays, he does not get the points in the MDM, so for the Data portion this would not be moderate. Risk is very subjective as @thomas7331 stated so even though it meets a moderate risk due to the antibiotic prescription, I would defer to his/her judgment.