Wiki level 2 or 3? all answers/perspectives welcome

[wynonna]

I've done research which indicates SNHL can carry a risk of dementia and falling (because the ears are involved in possible disequilibrium) which led me to see as a level 3 across the board for permanent hearing loss. This is because patient may decide not to treat which constitutes a risk to their cognition and safety. Plus a discussion and MDM takes place.
Do other coders see this as low risk? under (risk of complication and / or morbidity from patient management?)

 

[csperoni]

For outpatient, the leveling is based on: MDM or time.
MDM consists of problem, data and risk.
Problem: if chronic and stable, low (level 3). If chronic and not stable, then moderate (level 4); possibly but unlikely high (level 5). It all depends how severe the SNHL is and any exacerbation, progression, or side effects of treatment.
Data: assuming none, so minimal/none (level 2)
Risk: This is where you need to really level each visit based on the documentation. If SNHL can carry a risk, but the clinician is not documenting and discussing these risks and/or treatment options with the patient, then you cannot count them. The severity of SNHL can also play a factor here. You may have 2 patients with same SNHL diagnosis, but patient A is 88 y/o wheelchair bound with very mild SNHL in one ear, and patient B is a 42 y/o professional musician with significant SNHL in both ears. The management and risks for each of these patients with the same diagnosis could be different.

If you had to do your own research to determine the risks, then they are not currently being documented sufficiently to count them. As coders, we take the words on the page and translate into ICD10, CPT, HCPCs. It sounds like in your examples, the words are not on the page. It may be helpful to provide guidance to your providers regarding documentation. You should never tell your providers how to treat, but rather advise IF something is being discussed or decided to ensure that is reflected in the record.

 

[wynonna]

Thank you. That is very helpful. I'm concerned because my providers are billing 99213 across the board whenever patient comes in with permanent hearing loss. aka sensorineural hearing loss.
They are also reviewing AND ordering future hearing tests (1 audiometry, and 1 tympanometry so 2 cpt's). So there is also a thought process involved AND extra work in audio test interpretation and ordering. They are often clearing their patients for hearing aids.
How do you see these scenarios? Thank you Christine.

 

[csperoni]

There is never an "always" level for any diagnosis. That is why there are coders who are educated about coding guidelines. Yes, it might be 99213 95% of the time, but each visit should be coded based on documentation of this specific patient's care.
Regarding data for tests. 1) Review is included in ordering and you would count it at the order only. Exception for tests not ordered by your practice or tests ordered not at a visit. 2) If the test ordered has a professional component, and your practice is performing and billing the test, you count nothing toward data on the E/M. The practice is already being paid for the work of ordering/reviewing by performing the professional component of the test. I know nothing about audiology tests to know if there is a professional component.
From the 2021 AMA guidelines:
The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of MDM.
DATA SUMMARY: If the test has a professional component and you perform it, count no data. If the test does not have a professional component or your practice is not performing it, then count it at the order.

Regarding hearing aids, I have not seen any official guidance or example using hearing aids. I personally think it would fall under same risk as PT/OT and would count low risk.