Question In E/M level coding Medical necessity is moderate but problem related HPI elements is not there, can we give level 4.Thanks

ramana365

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Patient is established came with headache and fatigue with 1 week.patient had hypertension, Physician said continue medication.But in assessment Allergic rhinitis is there he treated with RX.Allergic rhinitis HPI elements is not there,but elements is there which related to HTN. So please can you suggest the appropriate level ?Thanks
 

Pathos

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In the example shown, there is not much to go with. You mention the History and MDM, however what about the Physical Exam? Don't forget that the History consists of more than just the HPI, but also the ROS and PFSMH as well. As you know, in order to determine the E/M level of an Established Patient, we will need 2 out of the 3 E/M components (History, Exam and/or MDM). Since you are not providing any Exam examples, I would have to default to the History and MDM as viable components.

Other coders might disagree, but when the provider explains "Continue medication", assigning the Risk can be a little troublesome. I would like to see at least the name of the drug and the status of the condition being treated.

Overall, I would like more information of the chart in order to determine the E/M level, otherwise this looks either like a 99212 or 99213.
 
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Thank you for your quick response. I did not include the HPI and Exam level as that is more clear in the documentation, I am having trouble trying to determine MDM, specifically as it pertains to risk to patient, but I see your point and thank you for that and thank you for your assessment. Very helpful. I have a few different scenarios regarding patient risk and I don't find the queues in the table of risk particularly helpful to these cancer scenarios. For example, when the patient is being followed after a mastectomy they may still be on tamoxifen and doing well. Does the fact that they are under active cancer treatment put the patient in the high risk box under management options selected? If not, where would you categorize it? There is no change of dose recommended. Another scenario is when the patient is currently undergoing chemo/radiation under the care of the oncologist, but still seeing the breast surgeon without any reports of problems. Again, no change recommended by the breast surgeon who diagnosed and is following the problem, but does the fact that the patient is undergoing chemo/radiation put the patient in the high risk box due to potential loss of life if the plan does not go well? Ultimately would you consider a patient currently undergoing chemo/radiation as high risk under management options for any doctor peripherally involved in their care? Finally, does high risk of developing br cancer based on genetic testing and strong family history come into play when considering the risk to the patient? Thanks in advance!
 
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