E/M

Hya726

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Greensburg, PA
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Can someone tel me if this is correct? A patient comes to urgent care due to a burn on rt hand from grease fire. No significant history. Provider cleaned burn, applied silvadene 1% topical cream and then applied dressing to the burn. Patient was also given an injection of ketorolac in the office and prescribed tylenol with codeine

Provider billed
99214
16029
96372
J1885

When I use the AAPC audit tool I’m only getting 99213 for the office visit. Am I missing something?
 

wynonna

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That may be because a burn is an acute, not a chronic problem. (low level under problems)
It may be new, but is there a moderate/high risk of morbidity? Is the prognosis uncertain?
 

csperoni

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If the only question is about the level of E/M:
The prescriptions get you to moderate risk (level 4). It does not seem there was any data (no tests ordered/reviewed, no independent historian, no discussion of management with external clinician, no independent interpretation of tests) which brings you to minimal/no data (level 2).
If the problem was low level (acute uncomplicated for level 3), your overall is 99213.
If the problem was moderate (acute complicated or acute with systemic symptoms for level 4), your overall is 99214.
From the AMA 2021 Outpatient guide:
Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.
Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness.
Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

Depending on the severity and documentation, either 99213 or 99214 may be correct.

I will note you also indicate 16029, which is not a valid CPT code. There are other similar CPTs for burn care, and many of them are NCCI edits with E/M services. Burn care is definitely not my expertise. I would advise you look at the documentation, and eliminate everything related to the burn care. Is what you have left significant and separately identifiable? If so, then an E/M might be appropriate along with the burn care code along with modifiers. If not, then you should not be coding an E/M.
 
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