wynonna
True Blue
|
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki level 2 or 3? exam and hx done but not included here
- Thread starter wynonna
- Start date
wynonna
True Blue
1 chronic and I see benign neo as low risk for a 99213.
Problem-low
Data--0
Risk of mgt-low
Do you agree?
Problem-low
Data--0
Risk of mgt-low
Do you agree?
The audit tool my organization uses gives the following examples for risk:
MINIMAL:
Rest
Gargles
Elastic bandages
Superficial dressings
Lab test requiring venipuncture
CXR
Ultrasound/Echo
EKG/EEG
KOH Prep
UA
LOW:
OTC drugs
Decision regarding minor surgery without identified risk factors
PT/OT
IV fluids
Physiologic tests not under stress (eg PFT)
Non-cardiovascular imaging studies with contrast
Superficial needle biopsies
Labs requiring arterial puncture
To me, a stable problem benign problem without any further treatment would fall under minimal risk, not low risk. I would code this 99212 with the information provided.
MINIMAL:
Rest
Gargles
Elastic bandages
Superficial dressings
Lab test requiring venipuncture
CXR
Ultrasound/Echo
EKG/EEG
KOH Prep
UA
LOW:
OTC drugs
Decision regarding minor surgery without identified risk factors
PT/OT
IV fluids
Physiologic tests not under stress (eg PFT)
Non-cardiovascular imaging studies with contrast
Superficial needle biopsies
Labs requiring arterial puncture
To me, a stable problem benign problem without any further treatment would fall under minimal risk, not low risk. I would code this 99212 with the information provided.
wynonna
True Blue
I was under the impression from a post earlier this year that::
MDM is low risk when the problem is CHRONIC, because it is over and above self-limited or minor.
Is this not the case?
So a level 3 or did I misunderstand prior post? Isn't self limited just for cold, insect bite, fungus and other such problems? I was told self limited or minor is when a condition will resolve with or without medical treatment. Anything more complicated would be at least a level 3.
Is that the case?
MDM is low risk when the problem is CHRONIC, because it is over and above self-limited or minor.
Is this not the case?
So a level 3 or did I misunderstand prior post? Isn't self limited just for cold, insect bite, fungus and other such problems? I was told self limited or minor is when a condition will resolve with or without medical treatment. Anything more complicated would be at least a level 3.
Is that the case?
Self limited or minor refers to the problem, which is only 1 of 3 elements of MDM. A chronic stable problem is level 3 FOR PROBLEM ONLY. Risk is a separate element. Generally, they will be similar but are certainly not always the same level. Depending on the treatment, a chronic stable problem might be level 2, 3, 4, or even 5 risk. You could have a self limited problem that the provider decides to write a prescription for
From the AMA 2021 guidelines:
One element used in selecting the level of service is the risk of complications and/or morbidity or mortality of patient management at an encounter. This is distinct from the risk of the condition itself.
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
Problem and risk are 2 separate elements, along with data, to determine your MDM level.
From the AMA 2021 guidelines:
One element used in selecting the level of service is the risk of complications and/or morbidity or mortality of patient management at an encounter. This is distinct from the risk of the condition itself.
Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
Problem and risk are 2 separate elements, along with data, to determine your MDM level.
I have a similar question. If the chart only documents 2 chronic conditions with one lab order, do we code it as level 2 or 3? Of so what's the rationale behind it? Because although table 1 satisfies for moderate as there is only one lab it doesn't satisfy table 2 for low. So it'll be minimal. The doubt is in the third column where there is no clear documentation on low risk of morbidity associated with diagnostic tests and treatment. Can we take one lab for low risk?
