Question How to decipher between low/moderate MDM

sinman0531

Networker
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33
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Tampa, FL
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I have a particular provider who is not a huge fan of documentation, and generally relies on his diagnoses and/or his prescriptions to justify billing a 99204/14 vs the 99203/13. According to all of the training he (and our other providers) have been given, anything Rx is going to fall under a "moderate" category, and OTC recommendations would be "low" complexity.

As a result, I have an EMN that he wants to send out with a 99204, with a lone Dx of L84 simply because he prescribed clobetasol 0.05% and urea 20%. I just cannot wrap my brain around any situation where topicals would make a callus a moderately complex issue. What am I missing? Or, how do I gently let him know he needs to consider not just the fact that he's writing a prescription, but the side effects and method of the Rx when looking at MDM?
 

sinman0531

Networker
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Tampa, FL
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Yes, I have my own chart with this information, as does my provider. As I said, according to the CE the providers have been given, because we are a specialist practice any type of Rx is automatically going to be a "moderate" level of complexity. My issue is how do I communicate to a provider that that is not the case, or am I just supposed to accept that callused hands can be moderately complex because topical creams were prescribed?
 

csperoni

True Blue
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Selden
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Prescription puts your risk at moderate (level 4.) You still need to meet level 4 for either the problem or data to use 99204/14. It's possible, but certainly not likely to have met level 4 for data as no tests would have been ordered or reviewed. That leaves problems addressed. Those would have to be some pretty serious callouses to justify level 4. Offhand, I would consider that level 2 for a minor problem. Perhaps you could get to level 3. The documentation is key. If it just said "callused hands", level 2. If it was documented that other treatments were tried and failed, or infection, etc then I could possibly understand a higher level.
 
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