level 2 or level 3

[mradula.chauhan@xpertdox.com]

Hi ! Just want to make sure if a patient comes in with sore throat or pharyngitis. Provider does a strep test. In this case, can we bill 99203/99213 as table A is satisfied. But table B is not satisfied. Although Table C says low risk of morbidity with additional diagnostic testing or treatment . Can we consider it there. Please help

 

[csperoni]

To code level 3, you must have 2 of 3 of problem, data and risk be low level.
Problem - you are stating it is low for an acute, uncomplicated illness. Keep in mind, depending on the particular severity of the problem and what else is going on, sore throat or pharyngitis might be considered straightforward for a minor problem, low for acute, uncomplicated illness, or moderate for acute illness with systemic symptoms.
Data - 1 test ordered/reviewed is straightforward.
Risk - you are not stating at all what the treatment plan is. Gargle with salt water - straightforward. Take Nyquil Q 4h - low. Prescription decision - moderate. Does the patient have underlying health conditions that are altering the treatment plan?
Each visit should be leveled on the documentation provided for that specific visit.

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

 

[mradula.chauhan@xpertdox.com]

Thanks a lot for your inputs.
for more clarification i am putting the scenario
HPI- ST and nausea, no fever, suspect viral vs strep, will treat if +
A/P- Strep Negative.
That's it . How should i code it level 3 or level 2?